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van der Goot WE, Duvivier RJ, Van Yperen NW, de Carvalho-Filho MA, Noot KE, Ikink R, Gans ROB, Kloeze E, Tulleken JE, Lammers AJJ, Jaarsma ADC, Bierman WFW. Psychological distress among frontline workers during the COVID-19 pandemic: A mixed-methods study. PLoS One 2021; 16:e0255510. [PMID: 34351970 PMCID: PMC8341539 DOI: 10.1371/journal.pone.0255510] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Novel virus outbreaks, such as the COVID-19 pandemic, may increase psychological distress among frontline workers. Psychological distress may lead to reduced performance, reduced employability or even burnout. In the present study, we assessed experienced psychological distress during the COVID-19 pandemic from a self-determination theory perspective. Methods This mixed-methods study, with repeated measures, used surveys (quantitative data) combined with audio diaries (qualitative data) to assess work-related COVID-19 experiences, psychological need satisfaction and frustration, and psychological distress over time. Forty-six participants (nurses, junior doctors, and consultants) completed 259 surveys and shared 60 audio diaries. Surveys and audio diaries were analysed separately. Results Quantitative results indicated that perceived psychological distress during COVID-19 was higher than pre-COVID-19 and fluctuated over time. Need frustration, specifically autonomy and competence, was positively associated with psychological distress, while need satisfaction, especially relatedness, was negatively associated with psychological distress. In the qualitative, thematic analysis, we observed that especially organisational logistics (rostering, work-life balance, and internal communication) frustrated autonomy, and unfamiliarity with COVID-19 frustrated competence. Despite many need frustrating experiences, a strong connection with colleagues and patients were important sources of relatedness support (i.e. need satisfaction) that seemed to mitigate psychological distress. Conclusion The COVID-19 pandemic resulted in an increase of psychological distress among frontline workers. Both need frustration and need satisfaction explained unique variance of psychological distress, but seemed to originate from different sources. Challenging times require healthcare organisations to better support their professionals by tailored formal and informal support. We propose to address both indirect (e.g. organisation) and direct (e.g. colleagues) elements of the clinical and social environment in order to reduce need frustration and enhance need satisfaction.
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Affiliation(s)
- Wieke E. van der Goot
- Martini Academy, Martini Hospital, Groningen, The Netherlands
- Center for Educational Development and Research in Health Sciences (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | - Robbert J. Duvivier
- Center for Educational Development and Research in Health Sciences (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Nico W. Van Yperen
- Department of Psychology, University of Groningen, Groningen, The Netherlands
| | - Marco A. de Carvalho-Filho
- Center for Educational Development and Research in Health Sciences (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- ICVS Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
| | - Kirsten E. Noot
- Center for Educational Development and Research in Health Sciences (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Renee Ikink
- Center for Educational Development and Research in Health Sciences (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rijk O. B. Gans
- Department of Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Eveline Kloeze
- Department of Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jaap E. Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A. J. Jolanda Lammers
- Department of Internal Medicine / Infectious Diseases, Isala, Zwolle, The Netherlands
| | - A. Debbie C. Jaarsma
- Center for Educational Development and Research in Health Sciences (CEDAR), Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Wouter F. W. Bierman
- Department of Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Leenstra NF, Jung OC, Cnossen F, Jaarsma ADC, Tulleken JE. Development and Evaluation of the Taxonomy of Trauma Leadership Skills-Shortened for Observation and Reflection in Training: A Practical Tool for Observing and Reflecting on Trauma Leadership Performance. Simul Healthc 2021; 16:37-45. [PMID: 32732816 PMCID: PMC7850591 DOI: 10.1097/sih.0000000000000474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Trauma leadership skills are increasingly being addressed in trauma courses, but few resources are available to systematically observe and debrief trainees' performances. The authors therefore translated their previously developed, extensive Taxonomy of Trauma Leadership Skills (TTLS) into a practical observation tool that is tailored to the vocabulary of clinician instructors and their workflow and workload during simulation-based training. METHODS In 2016 to 2018, the TTLS was subjected to practical evaluation in an iterative process of 2 stages. In the first stage, testing panels of trauma specialists observed excerpts from videotaped simulations and indicated from the list of elements which behaviors they felt were being shown. Any ambiguities or redundancy were addressed by rephrasing or combining elements. In the second stage, iterations were used in actual scenario training to observe and debrief trainees' performances. The instructors' recommendations resulted in further improvements of clarity, ease of use, and usefulness, until no new suggestions were raised. RESULTS The resultant "TTLS-Shortened for Observation and Reflection in Training" was given a simpler structure and more concrete and self-explanatory benchmarks. It contains 6 skill categories for evaluation, each with 4 to 6 benchmark behaviors. CONCLUSIONS The TTLS-Shortened for Observation and Reflection in Training is an important addition to other trauma assessment tools because of its specific focus on leadership skills. It helps set concrete performance expectations, simplify note taking, and target observations and debriefings. One central challenge was striking a balance between its conciseness and specificity. The authors reflected on how the decisions for the resultant structure ease and leverage the conduct of observations and performance debriefing.
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Cox EGM, Koster G, Baron A, Kaufmann T, Eck RJ, Veenstra TC, Hiemstra B, Wong A, Kwee TC, Tulleken JE, Keus F, Wiersema R, van der Horst ICC. Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill. Crit Care 2020; 24:14. [PMID: 31931844 PMCID: PMC6958607 DOI: 10.1186/s13054-019-2719-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients. Methods This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated. Results The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in non-ventilated than in ventilated patients. Conclusion The agreement between lung ultrasound and auscultation is poor. Trial registration NCT02912624. Registered on September 23, 2016.
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Affiliation(s)
- Eline G M Cox
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Geert Koster
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Aidan Baron
- Emergency, Cardiovascular, and Critical Care Research Group, Centre for Health and Social Care Research, Kingston University and St George's University, London, UK
| | - Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - T Corien Veenstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adrian Wong
- Department of Anaesthesiology and Intensive Care, Royal Surrey County Hospital, Guildford, UK
| | - Thomas C Kwee
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
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Reinke L, Haveman M, Horsten S, Falck T, van der Heide EM, Pastoor S, van der Hoeven JH, Absalom AR, Tulleken JE. The importance of the intensive care unit environment in sleep-A study with healthy participants. J Sleep Res 2019; 29:e12959. [PMID: 31833118 PMCID: PMC7154670 DOI: 10.1111/jsr.12959] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/20/2019] [Accepted: 11/12/2019] [Indexed: 11/29/2022]
Abstract
Sleep disruption is common among intensive care unit patients, with potentially detrimental consequences. Environmental factors are thought to play a central role in ICU sleep disruption, and so it is unclear why environmental interventions have shown limited improvements in objectively assessed sleep. In critically ill patients, it is difficult to isolate the influence of environmental factors from the varying contributions of non‐environmental factors. We thus investigated the effects of the ICU environment on self‐reported and objective sleep quality in 10 healthy nurses and doctors with no history of sleep pathology or current or past ICU employment participated. Their sleep at home, in an unfamiliar environment (‘Control’), and in an active ICU (‘ICU’) was evaluated using polysomnography and the Richard‐Campbell Sleep Questionnaire. Environmental sound, light and temperature exposure were measured continuously. We found that the control and ICU environment were noisier and warmer, but not darker than the home environment. Sleep on the ICU was perceived as qualitatively worse than in the home and control environment, despite relatively modest effects on polysomnography parameters compared with home sleep: mean total sleep times were reduced by 48 min, mean rapid eye movement sleep latency increased by 45 min, and the arousal index increased by 9. Arousability to an awake state by sound was similar. Our results suggest that the ICU environment plays a significant but partial role in objectively assessed ICU sleep impairment in patients, which may explain the limited improvement of objectively assessed sleep after environmental interventions.
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Affiliation(s)
- Laurens Reinke
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marjolein Haveman
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Sandra Horsten
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | | | - Johannes H van der Hoeven
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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van Bockel EAP, Walstock PA, van Mook WNKA, Arbous MS, Tepaske R, van Hemel TJD, Müller MCA, Delwig H, Tulleken JE. Entrustable professional activities (EPAs) for postgraduate competency based intensive care medicine training in the Netherlands: The next step towards excellence in intensive care medicine training. J Crit Care 2019; 54:261-267. [PMID: 31733630 DOI: 10.1016/j.jcrc.2019.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/30/2019] [Accepted: 09/11/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The Competency Based Training in Intensive Care Education (CoBaTrICE) programme developed common standards of ICM training by describing competencies of an intensivist. Entrustable Professional Activities (EPAs) of Intensive Care Medicine (ICM) (EPAsICM) are presented as a new workplace-based assessment tool in competency-based training of intensivists. EPAs are activities to be entrusted to a trainee once he (or she) has attained competence. EPAs emphasise the role of trust between trainees and supervisors. EPAs bridge the gap between competencies and competence. METHODS An expert panel of ICM (vice)programme directors and intensivists in The Netherlands integrated the CoBaTrICE and CanMEDS competencies into EPAsICM. Comment and feedback was sought from other ICM programme directors and educational experts and processed in the final version of EPAsICM before implementation in the Dutch ICM training programme. RESULTS A list of 15 EPAsICM are considered to reflect the spectrum of clinical practice while incorporating the competencies of CoBaTrICE and CanMEDS. The grading system is designed as a 5-point entrustment scale based on the amount of supervision a trainee needs, aligning with daily judgement of trainees by intensivists. CONCLUSION EPAsICM is an assessment tool that formalises entrustment decisions and can be a valuable addition in international ICM training.
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Affiliation(s)
- Esther A P van Bockel
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands.
| | - Pieter A Walstock
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands
| | - Walther N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center, P. Debyelaan 25, 6202, AZ, Maastricht, the Netherlands; School of Health Professions Education, Maastricht University, the Netherlands
| | - M Sesmu Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
| | - Robert Tepaske
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care Medicine, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Tina J D van Hemel
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
| | - Marcella C A Müller
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care Medicine, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Hans Delwig
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands
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Affiliation(s)
- L Reinke
- Department of Critical Care, University of Groningen, University Medical Center Groningen, NL-9713AV Groningen, The Netherlands
| | - J E Tulleken
- Department of Critical Care, University of Groningen, University Medical Center Groningen, NL-9713AV Groningen, The Netherlands
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Leenstra NF, Johnson A, Jung OC, Holman ND, Hofstra LS, Tulleken JE. Challenges for conducting and teaching handovers as collaborative conversations: an interview study at teaching ICUs. Perspect Med Educ 2018; 7:302-310. [PMID: 30187389 PMCID: PMC6191396 DOI: 10.1007/s40037-018-0448-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Whereas medical shift handovers are increasingly recognized to fulfil important functions beyond information transfer, studies suggest that shift handovers continue to be variably used for reflection, learning or discussion. Little is known of the dynamics of incorporating such functions into ICU shift handovers, resulting in a challenge for the design of educational programs whose underlying philosophies align with the specific requirements of the ICU. METHODS Intensivists, residents and fellows (n = 21) from three ICUs were interviewed to determine perceptions of handover functionality and the boundaries to what must or can be achieved in handover conversations. Interviews were analyzed to isolate training requirements and factors that challenge interactions. RESULTS The analysis revealed that ICU physicians value three functions for shift handovers: information transfer, enhancing shared understanding and decision-making, and learning. The functions towards which physicians are oriented were found to be affected by situational characteristics of cases, individuals, teams, and the unit workflow. Whereas some factors are helpful cues for determining communication needs, others raise dilemmas and misaligned expectations with regards to what can be achieved in the handover. DISCUSSION Our findings add to the growing case for the education of handovers in complex settings to involve more than information transfers. As residents gain experience, training should be gradually shifted towards more fluid and adaptable approaches to the handover and residents' ability to engage in joint reflections and discussions. Challenges for engaging in such interactions need to be alleviated, in order to allow the redefinition of handovers as potential sources of safety and learning, rather than error.
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Affiliation(s)
- Nico F Leenstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Addie Johnson
- Department of Psychology, University of Groningen, Groningen, The Netherlands
| | - Oliver C Jung
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole D Holman
- Department of Intensive Care, Martini Hospital Groningen, Groningen, The Netherlands
| | - Lieuwe S Hofstra
- Department Intensive Care Medicine, Scheper Hospital, Emmen, The Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Horsten S, Reinke L, Absalom AR, Tulleken JE. Systematic review of the effects of intensive-care-unit noise on sleep of healthy subjects and the critically ill. Br J Anaesth 2017; 120:443-452. [PMID: 29452801 DOI: 10.1016/j.bja.2017.09.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 08/30/2017] [Accepted: 12/01/2017] [Indexed: 01/17/2023] Open
Abstract
Intensive-care-unit (ICU) patients exhibit disturbed sleeping patterns, often attributed to environmental noise, although the relative contribution of noise compared to other potentially disrupting factors is often debated. We therefore systematically reviewed studies of the effects of ICU noise on the quality of sleep to determine to what extent noise explains the observed sleep disruption, using the Cochrane Collaboration method for non-randomized studies. Searches in Scopus, PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library were conducted until May 2017. Twenty papers from 18 studies assessing sleep of adult patients and healthy volunteers in the ICU environment, whilst recording sound levels, were included and independently reviewed by two reviewers. We found that the numbers of arousals between the baseline and the ICU noise condition in healthy subjects differed significantly (mean difference 9.59; 95% confidence interval 2.48-16.70). However, there was considerable heterogeneity between studies (I2 94%, P < 0.00001), and all studies suffered from a considerable risk of bias. The meta-analysis of results was hampered by widely varying definitions of sound parameters between studies and a general lack of detailed description of methods used. It is, therefore, currently impossible to quantify the extent to which noise contributes to sleep disruption among ICU patients, and thus, the potential benefit from noise reduction remains unclear. Regardless, the majority of the observed sleep disturbances remain unexplained. Future studies should, therefore, also focus on more intrinsic sleep-disrupting factors in the ICU environment.
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Affiliation(s)
- S Horsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, NL-9713AV Groningen, The Netherlands
| | - L Reinke
- Department of Critical Care, University of Groningen, University Medical Center Groningen, NL-9713AV Groningen, The Netherlands.
| | - A R Absalom
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, NL-9713AV Groningen, The Netherlands
| | - J E Tulleken
- Department of Critical Care, University of Groningen, University Medical Center Groningen, NL-9713AV Groningen, The Netherlands
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Dijkstra IS, Brand PLP, Pols J, Delwig H, Jaarsma DADC, Tulleken JE. Are graduated intensivists prepared for practice? A case study from The Netherlands. J Crit Care 2017; 42:47-53. [PMID: 28679114 DOI: 10.1016/j.jcrc.2017.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/12/2016] [Accepted: 01/22/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE An evaluation of the alignment between intensive care medicine (ICM) training and practice provides valuable information for the development of ICM training. Therefore this study examines how well recently licensed intensivists feel prepared for practice and whether intensivists from different background specialties attain comparable preparedness rates. METHODS An inventory was developed to cover the tasks that constitute ICM practice. Two hundred five recently licensed Dutch intensivists received a questionnaire in which they could indicate how well their ICM training programme prepared them for these tasks on a 5-point Likert scale. RESULTS Ninety-one respondents returned the questionnaire (response 45%). Respondents felt excellently prepared for 67 tasks, well prepared for 16 tasks, marginally sufficiently prepared for 6 tasks and insufficiently prepared for 15 tasks. Intensivists from anaesthesiology felt better prepared for IC specific activities (mean 4.25, SD 0.38) than those from internal medicine (mean 4.01, SD 0.40, P=.02).Average scores on tasks related to medical expertise were relatively high while tasks relating to management and leadership, science and professional development scored lower. CONCLUSIONS Although recently licensed intensivists are well prepared for most tasks in ICM, lower preparedness scores on tasks related to leadership and management, science, and professional development call for re-evaluation of the current curriculum.
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Affiliation(s)
- Ids S Dijkstra
- Wenckebach Institute, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Paul L P Brand
- Wenckebach Institute, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Princess Amalia Children's Centre, Isala Hospital, Zwolle, The Netherlands
| | - Jan Pols
- Center for Educational Development and Research in Health Professions, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans Delwig
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Debbie A D C Jaarsma
- Center for Educational Development and Research in Health Professions, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
Background: To evaluate the possibility of preventing endotoxin induced renal damage by p38-MAPK inhibition in a human model. Design and Methods: Twenty-one healthy young male volunteers received 4 ng/kg Escherichia coli endotoxin as a single dose. Four groups of volunteers received an oral dose of placebo or 350, 700 or 1400 mg RWJ-67657, a p38-MAPK inhibitor, 20 min before endotoxin infusion. Urine samples were collected at set time intervals. The urinary excretion rate of β2-microglobulin and N-acetyl-β-D-glucosaminidase, as indicators of tubular dysfunction was determined. Results: There was a significant increase of β2-microglobulin and N-acetyl-β-D-glucosaminidase urine excretion rate after endotoxin infusion in the placebo group. p38-MAPK inhibition prevented the increase of markers for tubulopathy. Conclusions: Endotoxin infusion induces measurable tubular damage. Blocking the p38-MAPK may prevent this damage. The mechanism is unclear, but blocking TNF-α release is a possible explanation.
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Affiliation(s)
- Jan G. Zijlstra
- Intensive and Respiratory Care Unit, Department of Internal Medicine, University Hospital Groningen, Groningen, The Netherlands
| | - Jaap E. Tulleken
- Intensive and Respiratory Care Unit, Department of Internal Medicine, University Hospital Groningen, Groningen, The Netherlands,
| | - Jack J.M. Ligtenberg
- Intensive and Respiratory Care Unit, Department of Internal Medicine, University Hospital Groningen, Groningen, The Netherlands
| | - Peter de Boer
- R. W. Johnson Pharmaceutical Research Institute, Bassersdorf, Switzerland
| | - Tjip S. van der Werf
- Intensive and Respiratory Care Unit, Department of Internal Medicine, University Hospital Groningen, Groningen, The Netherlands
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VAN Mook WN, Arbous SM, Delwig H, VAN Hemel-Rintjap TJ, Tepaske R, Tulleken JE, VAN DER Vleuten CP. Progress testing in intensive care medicine training: useful and feasible?! Minerva Anestesiol 2016; 82:711-719. [PMID: 26576859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
So far the in-training assessment of knowledge is perhaps underrepresented in postgraduate assessment frameworks in intensive care medicine (ICM). In most contemporary training programs a predominant emphasis is placed on workplace based learning and workplace based assessment. This article provides a concise general background on the nature and use of progress testing, and touches upon potential strengths, and constraints regarding its potential implementation and use in the postgraduate ICM training programs.
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Affiliation(s)
- Walther N VAN Mook
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands -
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Leenstra NF, Jung OC, Johnson A, Wendt KW, Tulleken JE. Taxonomy of Trauma Leadership Skills: A Framework for Leadership Training and Assessment. Acad Med 2016; 91:272-281. [PMID: 26352763 DOI: 10.1097/acm.0000000000000890] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE Good leadership is essential for optimal trauma team performance, and targeted training of leadership skills is necessary to achieve such leadership proficiency. To address the need for a taxonomy of leadership skills that specifies the skill components to be learned and the behaviors by which they can be assessed across the five phases of trauma care, the authors developed the Taxonomy of Trauma Leadership Skills (TTLS). METHOD Critical incident interviews were conducted with trauma team leaders and members from different specialties-emergency physicians, trauma surgeons, anesthesiologists, and emergency ward nurses-at three teaching hospitals in the Netherlands during January-June 2013. Data were iteratively analyzed for examples of excellent leadership skills at each phase of trauma care. Using the grounded theory approach, elements of excellent leadership skills were identified and classified. Elements and behavioral markers were sorted and categorized using multiple raters. In a two-round verification process in late 2013, the taxonomy was reviewed and rated by trauma team leaders and members from the multiple specialties for its coverage of essential items. RESULTS Data were gathered from 28 interviews and 14 raters. The TTLS details 5 skill categories (information coordination, decision making, action coordination, communication management, and coaching and team development) and 37 skill elements. The skill elements are captured by 67 behavioral markers. The three-level taxonomy is presented according to five phases of trauma care. CONCLUSIONS The TTLS provides a framework for teaching, learning, and assessing team leadership skills in trauma care and other complex, acute care situations.
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Affiliation(s)
- Nico F Leenstra
- N.F. Leenstra is psychologist, Department of Traumatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. O.C. Jung is staff anesthesiologist, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. A. Johnson is professor, Department of Psychology, University of Groningen, Groningen, the Netherlands. K.W. Wendt is chief, Department of Traumatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. J.E. Tulleken is professor and staff intensivist, Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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13
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Reinke L, van der Hoeven JH, van Putten MJAM, Dieperink W, Tulleken JE. Intensive care unit depth of sleep: proof of concept of a simple electroencephalography index in the non-sedated. Crit Care 2014; 18:R66. [PMID: 24716479 PMCID: PMC4057034 DOI: 10.1186/cc13823] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/26/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Intensive care unit (ICU) patients are known to experience severely disturbed sleep, with possible detrimental effects on short- and long- term outcomes. Investigation into the exact causes and effects of disturbed sleep has been hampered by cumbersome and time consuming methods of measuring and staging sleep. We introduce a novel method for ICU depth of sleep analysis, the ICU depth of sleep index (IDOS index), using single channel electroencephalography (EEG) and apply it to outpatient recordings. A proof of concept is shown in non-sedated ICU patients. METHODS Polysomnographic (PSG) recordings of five ICU patients and 15 healthy outpatients were analyzed using the IDOS index, based on the ratio between gamma and delta band power. Manual selection of thresholds was used to classify data as either wake, sleep or slow wave sleep (SWS). This classification was compared to visual sleep scoring by Rechtschaffen & Kales criteria in normal outpatient recordings and ICU recordings to illustrate face validity of the IDOS index. RESULTS When reduced to two or three classes, the scoring of sleep by IDOS index and manual scoring show high agreement for normal sleep recordings. The obtained overall agreements, as quantified by the kappa coefficient, were 0.84 for sleep/wake classification and 0.82 for classification into three classes (wake, non-SWS and SWS). Sensitivity and specificity were highest for the wake state (93% and 93%, respectively) and lowest for SWS (82% and 76%, respectively). For ICU recordings, agreement was similar to agreement between visual scorers previously reported in literature. CONCLUSIONS Besides the most satisfying visual resemblance with manually scored normal PSG recordings, the established face-validity of the IDOS index as an estimator of depth of sleep was excellent. This technique enables real-time, automated, single channel visualization of depth of sleep, facilitating the monitoring of sleep in the ICU.
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Affiliation(s)
- Laurens Reinke
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700RB, The Netherlands
- University of Twente, MIRA Institute for Biomedical Technology and Technical Medicine, NL-7500 AE Enschede, the Netherlands
| | - Johannes H van der Hoeven
- Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700RB, the Netherlands
| | - Michel JAM van Putten
- University of Twente, MIRA Institute for Biomedical Technology and Technical Medicine, NL-7500 AE Enschede, the Netherlands
| | - Willem Dieperink
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700RB, The Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700RB, The Netherlands
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Ten Have ECM, Hagedoorn M, Holman ND, Nap RE, Sanderman R, Tulleken JE. Assessing the quality of interdisciplinary rounds in the intensive care unit. J Crit Care 2013; 28:476-82. [PMID: 23428713 DOI: 10.1016/j.jcrc.2012.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 11/10/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Interdisciplinary rounds (IDRs) in the intensive care unit (ICU) are increasingly recommended to support quality improvement, but uncertainty exists about assessing the quality of IDRs. We developed, tested, and applied an instrument to assess the quality of IDRs in ICUs. MATERIALS AND METHODS Delphi rounds were done to analyze videotaped patient presentations and elaborated together with previous literature search. The IDR Assessment Scale was developed, statistically tested, and applied to 98 videotaped patient presentations during 22 IDRs in 3 ICUs for adults in 2 hospitals in Groningen, The Netherlands. RESULTS The IDR Assessment Scale had 19 quality indicators, subdivided in 2 domains: "patient plan of care" and "process." Indicators were "essential" or "supportive." The interrater reliability of 9 videotaped patient presentations among at least 3 raters was satisfactory (κ = 0.85). The overall item score correlations between 3 raters were excellent (r = 0.80-0.94). Internal consistency in 98 videotaped patient presentations was acceptable (α = .78). Application to IDRs demonstrated that indicators could be unambiguously rated. CONCLUSIONS The quality of IDRs in the ICU can be reliably assessed for patient plan of care and process with the IDR Assessment Scale.
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Affiliation(s)
- Elsbeth C M Ten Have
- Directorate Medical Affairs, Quality and Safety, University Medical Center Groningen, Groningen, The Netherlands.
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de Leeuw K, Meertens JHJM, van der Horst ICC, van der Berg AP, Ligtenberg JJM, Tulleken JE, Zijlstra JG. "Acute liver failure": the heart may be the matter. Acta Clin Belg 2011; 66:236-9. [PMID: 21837938 DOI: 10.2143/acb.66.3.2062557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hypoxic hepatitis secondary to heart failure is a known and treatable cause of liver failure. The diagnosis may be difficult, especially when symptoms of heart failure are absent. We present two patients who were transferred to our hospital with the diagnosis of acute liver failure to be screened for a liver transplantation. Both patients had increased serum levels ofaminotransferases, lactic acidosis, coagulation disorders, and non-specific clinical symptoms. Echocardiography revealed right ventricular dysfunction. Treatment with inotropes resulted in a fast normalization of liver enzymes, acidosis and coagulation, confirming the diagnosis hypoxic hepatitis. In conclusion, when the cause of acute liver dysfunction is unclear, hypoxic hepatitis due to heart failure should be considered and echocardiography should be performed, even when symptoms are non-specific for heart failure.
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Affiliation(s)
- K de Leeuw
- Department of Internal Medicine, Division of Rheumatology and Clinical Immunology, University Medical Centre Groningen, the Netherlands.
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Arnold KS, Tulleken JE, Ligtenberg JJM, Zijlstra JG. Can we afford open-ended ICU care? Yes we can, but ... Crit Care 2010; 14:447; author reply 447. [PMID: 21067527 PMCID: PMC3219268 DOI: 10.1186/cc9267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Aardema H, Tulleken JE, van den Biggelaar RJM, Wolters BA, de Jager CM, Boucher CAB, Riezebos-Brilman A. [Fatal pneumonitis due to oseltamivir-resistant new influenza A(H1N1) in the case of an intensive care patient]. Ned Tijdschr Geneeskd 2010; 154:A1634. [PMID: 20482913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
A 58-year-old man was submitted to our intensive care ward with respiratory failure due to pneumonitis. He had previously been treated for non-Hodgkin lymphoma by autologous stem cell transplantation, as a result of which bone marrow function was reduced. Further analysis showed infection with new influenza A(H1N1); typing revealed an oseltamivir-resistant subpopulation (H275Y). The patient was treated with oseltamivir and intravenously with zanamivir, but died of respiratory disease progression. This is the first published case of oseltamivir-resistant new influenza A(H1N1) infection in the Netherlands.
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Affiliation(s)
- Heleen Aardema
- Universitair Medisch Centrum Groningen, Afd. Intensive Care Volwassenen, The Netherlands.
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Aardema H, Dijkema LM, Lazonder MG, Ligtenberg JJM, Tulleken JE, Zijlstra JG. Value and price of ventilator-associated pneumonia surveillance as a quality indicator. Crit Care 2010; 14:403. [PMID: 20156322 PMCID: PMC2875482 DOI: 10.1186/cc8189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Pickkers P, Snellen F, Rogiers P, Bakker J, Jorens P, Meulenbelt J, Spapen H, Tulleken JE, Lins R, Ramael S, Bulitta M, van der Hoeven JG. Clinical pharmacology of exogenously administered alkaline phosphatase. Eur J Clin Pharmacol 2008; 65:393-402. [PMID: 19048243 DOI: 10.1007/s00228-008-0591-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 11/11/2008] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the clinical pharmacology of exogenous alkaline phosphatase (AP). METHODS Randomized, double-blind, placebo-controlled sequential protocols of (1) ascending doses and infusion duration (volunteers) and (2) fixed dose and duration (patients) were conducted at clinical pharmacology and intensive care units. A total of 103 subjects (67 male volunteers and 36 patients with severe sepsis) were administered exogenous, 10-min IV infusions (three ascending doses) or 24-72 h continuous (132.5-200 U kg(-1) 24 h(-1)) IV infusion with/without preceding loading dose and experimental endotoxemia for evaluations of pharmacokinetics, pharmacodynamics, safety parameters, antigenicity, inflammatory markers, and outcomes. RESULTS Linearity and dose-proportionality were shown during 10-min infusions. The relatively short elimination half-life necessitated a loading dose to achieve stable enzyme levels. Pharmacokinetic parameters in volunteers and patients were similar. Innate immunity response was not significantly influenced by AP, while renal function significantly improved in sepsis patients. CONCLUSIONS The pharmacokinetics of exogenous AP is linear, dose-proportional, exhibit a short half-life, and are not influenced by renal impairment or dialysis.
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Affiliation(s)
- P Pickkers
- Department of Intensive Care Medicine (551), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Sleeswijk ME, Tulleken JE, Van Noord T, Meertens JHJM, Ligtenberg JJM, Zijlstra JG. Efficacy of magnesium-amiodarone step-up scheme in critically ill patients with new-onset atrial fibrillation: a prospective observational study. J Intensive Care Med 2008; 23:61-6. [PMID: 18320707 DOI: 10.1177/0885066607310181] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Amiodarone is considered a first-choice antiarrhythmic drug in critically ill patients with new-onset atrial fibrillation (AF). However, evidence supporting the use of this potentially toxic drug in critically ill patients is scarce. Magnesium sulphate (MgSO4) has shown to be effective for both rate and rhythm control, to act synergistically with antiarrhythmic drugs, and to prevent proarrhythmia. Treatment with MgSO4 may reduce the need for antiarrhythmic drugs such as amiodarone in critically ill patients with new-onset atrial fibrillation. The efficacy of a new institutional protocol was evaluated. Patients were treated with a new institutional protocol for new-onset atrial fibrillation in critically ill patients. An MgSO4 bolus (0.037 g/kg body weight in 15 minutes) was followed by continuous infusion (0.025 g/kg body weight/h). Intravenous amiodarone (loading dose 300 mg, followed by continuous infusion of 1200 mg/24 h) was given to those not responding to MgSO4 within 1 hour. Clinical response was defined as conversion to sinus rhythm or decrease in heart rate <110 beats/min. Sixteen of the 29 patients responded to MgSO4 monotherapy, whereas the addition of amiodarone was needed in 13 patients. Median (range) time until conversion to sinus rhythm after MgSO4 was 2 (1-45) hours. Median (range) conversion time in patients requiring amiodarone was 4 (2-78) hours, and median (range) conversion time in all patients was 3 (1-78) hours. The 24-hour conversion rate was 90%. Relapse atrial fibrillation was seen in 7 patients. The magnesium-amiodarone step-up scheme reduces the need for amiodarone, effectively converts new-onset atrial fibrillation into a sinus rhythm within 24 hours, and seems to be safe in critically ill patients.
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Affiliation(s)
- Mengalvio E Sleeswijk
- Intensive & Respiratory Care Unit, Department of Internal Medicine, University of Groningen, Groningen, The Netherlands.
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Sleeswijk ME, Van Noord T, Tulleken JE, Ligtenberg JJM, Girbes ARJ, Zijlstra JG. Clinical review: treatment of new-onset atrial fibrillation in medical intensive care patients--a clinical framework. Crit Care 2008; 11:233. [PMID: 18036267 PMCID: PMC2246197 DOI: 10.1186/cc6136] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation occurs frequently in medical intensive care unit patients. Most intensivists tend to treat this rhythm disorder because they believe it is detrimental. Whether atrial fibrillation contributes to morbidity and/or mortality and whether atrial fibrillation is an epiphenomenon of severe disease, however, are not clear. As a consequence, it is unknown whether treatment of the arrhythmia affects the outcome. Furthermore, if treatment is deemed necessary, it is not known what the best treatment is. We developed a treatment protocol by searching for the best evidence. Because studies in medical intensive care unit patients are scarce, the evidence comes mainly from extrapolation of data derived from other patient groups. We propose a treatment strategy with magnesium infusion followed by amiodarone in case of failure. Although this strategy seems to be effective in both rhythm control and rate control, the mortality remained high. A randomised controlled trial in medical intensive care unit patients with placebo treatment in the control arm is therefore still defendable.
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Aardema H, Meertens JHJM, Ligtenberg JJM, Peters-Polman OM, Tulleken JE, Zijlstra JG. Organophosphorus pesticide poisoning: cases and developments. Neth J Med 2008; 66:149-153. [PMID: 18424861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Self-poisoning with organophosphate pesticides is a major health problem world-wide. Through the inhibition of acetylcholinesterase, organophosphorus poisoning is characterised by the clinical picture of acute cholinergic crisis. Other manifestations are the intermediate neurotoxic syndrome and delayed polyneuropathy. In the Western world, the occurrence of organophosphorus poisoning is less prevalent due to the declining availability of organophosphate pesticides, which could render the recognition of this particular type of intoxication and its specific treatment more difficult. In this article we discuss some recent developments and treatment dilemmas, illustrated by cases from our clinic, followed by a review of the current recommendations in the treatment of organophosphate poisoning.
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Affiliation(s)
- H Aardema
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.
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Olgers TJ, Tulleken JE, Monteban-Kooistra WE, Ligtenberg JJM, Meertens JH, Zijlstra JG. [Serious intoxication with hydroxychloroquine, with haemodynamic instability: a case report supporting treatment with diazepam]. Ned Tijdschr Geneeskd 2008; 152:509-512. [PMID: 18389886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A 37-year-old woman was admitted to the emergency room because of an autointoxication with hydroxychloroquine, leading to haemodynamic instability. Treatment consisted of the rapid administration of intravenous diazepam, after which the hypotension recovered rapidly even though no vasoactive medication was given. Treatment with diazepam has been advised in the Netherlands for many years in case of severe hydroxychloroquine intoxication, despite the fact that convincing evidence for its use is lacking. On the basis of the experience with the relevant cases, the administration of diazepam, 2 mg/kg initially followed by 2 mg/kg/24 hours as a continuous infusion, should certainly be considered for supportive treatment in the ICU in case of severe haemodynamic instability.
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Affiliation(s)
- T J Olgers
- Universitair Medisch Centrum Groningen, afd. Intensive Care, Postbus 30.001, 9700 RB Groningen
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Peters-Polman OM, Zijlstra JG, Tulleken JE, Meertens JH, Ligtenberg JJ. Prognostic pessimism: Not all bad? BMJ 2007; 335:1225-6. [PMID: 18079519 PMCID: PMC2137044 DOI: 10.1136/bmj.39423.448681.1f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Meertens JHJM, Monteban-Kooistra WE, Tulleken JE, Ligtenberg JJM, Zijlstra JG. [Again new resuscitation guidelines (2006): justification, costs and potential confusion]. Ned Tijdschr Geneeskd 2007; 151:1874-7. [PMID: 17902560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The last revision of the Dutch resuscitation guidelines, a translation of the European Resuscitation Council Guidelines 2005, is based on the recommendations of the International Liaison Committee on Resuscitation (ILCOR). The previous Dutch guidelines were issued in 2002. Most changes are based on laboratory studies and retrospective analyses. The most important changes are: recognizing circulatory arrest on unresponsiveness and abnormal breathing; a new ratio of chest compressions to ventilations i.e. 30:2 instead of 15:2; and following the procedure of checking the airway (A), taking over the circulation (C) and breathing (B). Furthermore in the event of ventricular fibrillation or ventricular tachycardia with no pulsations then one defibrillator shock only is to be given; this is in contrast with the previous application of cycles of 3 shocks. The work and costs of implementation involved in the revision of resuscitation guidelines are tremendous, especially in view of the huge number of laypersons who need to be retrained. Also, frequent changes of guidelines may cause confusion and have a negative effect on the quality of resuscitation. Therefore, it is not evident that the benefits of this revision justify its costs. It would be good to prospectively evaluate the effectiveness and costs of this revision. In the future, these data might help to decide when altered international recommendations should be translated into new Dutch resuscitation guidelines. Alternative strategies should be considered, for example only changing the guidelines for advanced life support.
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Affiliation(s)
- J H J M Meertens
- Universitair Medisch Centrum Groningen, afd. Intensive Care en Beademing, Postbus 30.001, 9700 RB Groningen.
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Meertens JHJM, Monteban-Kooistra WE, Ligtenberg JJM, Tulleken JE, Zijlstra JG. Severe hypoglycemia following venlafaxine intoxication: a case report. J Clin Psychopharmacol 2007; 27:414-5. [PMID: 17632237 DOI: 10.1097/01.jcp.0000280311.58495.ee] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oosterhuis JK, van den Berg G, Monteban-Kooistra WE, Ligtenberg JJM, Tulleken JE, Meertens JHJM, Zijlstra JG. Life-threatening Pneumocystis jiroveci pneumonia following treatment of severe Cushing's syndrome. Neth J Med 2007; 65:215-7. [PMID: 17587649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
We describe two patients with a severe Cushing's syndrome due to ectopic production of ACTH. Both patients developed a life-threatening Pneumocystis jiroveci pneumonia (PCP) shortly after treatment of the hypercortisolism was started by means of inhibition of production of glucocorticoids and glucocorticoid receptor blockade. We presume that the restored immune response elicited the clinical symptoms of the opportunistic, previously subclinical Pneumocystis jiroveci infection. The immunocompromised state and the delicate glucocorticoid balance in patients with a severe Cushing's syndrome necessitate a specific diagnostic and therapeutic approach.
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Affiliation(s)
- J K Oosterhuis
- Department of Anaesthesiology, Groningen University Medical Center, University of Groningen, Groningen, the Netherlands
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Droogh JM, Noppers IM, Tulleken JE, Meertens JH, Ligtenberg JJ, Monteban-Kooistra WE, Zijlstra JG. Comment on Mackenzie and Woodhouse: C-reactive protein concentrations during bacteraemia: a comparison between patients with and without liver dysfunction. Intensive Care Med 2007; 33:561; author reply 563-4. [PMID: 17262187 PMCID: PMC1915629 DOI: 10.1007/s00134-006-0526-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2006] [Indexed: 11/26/2022]
Affiliation(s)
- Joep M. Droogh
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands
| | - Ingeborg M. Noppers
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands
| | - Jaap E. Tulleken
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands
| | - John H. Meertens
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands
| | - Jack J. Ligtenberg
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands
| | - Wilma E. Monteban-Kooistra
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands
| | - Jan G. Zijlstra
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, Netherlands
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Meertens JHJM, Monteban-Kooistra WE, Veldhuis CA, Ligtenberg JJM, Zijlstra JG, Tulleken JE. Inconsistencies in new Advanced Life Support guidelines: The sequence of drug and shock delivery. Resuscitation 2007; 72:496-7; author reply 497. [PMID: 17240516 DOI: 10.1016/j.resuscitation.2006.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Accepted: 10/13/2006] [Indexed: 11/16/2022]
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Corstjens AM, Ligtenberg JJM, van der Horst ICC, Spanjersberg R, Lind JSW, Tulleken JE, Meertens JHJM, Zijlstra JG. Accuracy and feasibility of point-of-care and continuous blood glucose analysis in critically ill ICU patients. Crit Care 2007; 10:R135. [PMID: 16981981 PMCID: PMC1751062 DOI: 10.1186/cc5048] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Revised: 08/22/2006] [Accepted: 09/18/2006] [Indexed: 01/08/2023]
Abstract
INTRODUCTION To obtain strict glucose regulation, an accurate and feasible bedside glucometry method is essential. We evaluated three different types of point-of-care glucometry in seriously ill intensive care unit (ICU) patients. The study was performed as a single-centre, prospective, observational study in a 12-bed medical ICU of a university hospital. METHODS Patients with an expected ICU stay of more than 48 hours were included. Because the reference laboratory delivers glucose values after approximately 30 to 60 minutes, which is too slow to use in a glucose regulation protocol and for calibration of the subcutaneous continuous glucose monitoring system (CGMS) (CGMS System Gold), we first validated the ICU-based blood gas/glucose analyser ABL715 (part 1 of the study). Subsequently, part 2 was performed: after inserting (and calibrating) the subcutaneous CGMS, heparinised arterial blood samples were drawn from an arterial line every 6 hours and analysed on both the Precision PCx point-of-care meter using test strips and on the blood gas/glucose analyser ABL715. CGMS glucose data were downloaded after 24 to 72 hours. The results of the paired measurements were analysed as a scatter plot by the method of Bland and Altman and were expressed as a correlation coefficient. RESULTS Part 1: Four hundred and twenty-four blood samples were drawn from 45 critically ill ICU patients. The ICU-based blood gas/glucose analyser ABL715 provided a good estimate of conventional laboratory glucose assessment: the correlation coefficient was 0.95. In the Clarke error grid, 96.8% of the paired measurements were in the clinically acceptable zones A and B. Part 2: One hundred sixty-five paired samples were drawn from 19 ICU patients. The Precision PCx point-of-care meter showed a correlation coefficient of 0.89. Ninety-eight point seven percent of measurements were within zones A and B. The correlation coefficient for the subcutaneous CGMS System Gold was 0.89. One hundred percent of measurements were within zones A and B. CONCLUSION The ICU-based blood glucose analyser ABL715 is a rapid and accurate alternative for laboratory glucose determination and can serve as a standard for ICU blood glucose measurements. The Precision PCx is a good alternative, but feasibility may be limited because of the blood sample handling. The subcutaneous CGMS System Gold is promising, but real-time glucose level reporting is necessary before it can be of clinical use in the ICU. When implementing a glucose-insulin algorithm in patient care or research, one should realise that the absolute glucose level may differ systematically among various measuring methods, influencing targeted glucose levels.
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Affiliation(s)
- Anouk M Corstjens
- Department of Anesthesiology, University Medical Center Groningen, P.O. Box 30.001, NL-9700 RB, Groningen, The Netherlands
| | - Jack JM Ligtenberg
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, P.O. Box 30.001, NL-9700 RB, Groningen, The Netherlands
| | - Iwan CC van der Horst
- Department of Cardiology, University Medical Center Groningen, P.O. Box 30.001, NL-9700 RB Groningen, The Netherlands
| | - Rob Spanjersberg
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, P.O. Box 30.001, NL-9700 RB, Groningen, The Netherlands
| | - Joline SW Lind
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, P.O. Box 30.001, NL-9700 RB, Groningen, The Netherlands
| | - Jaap E Tulleken
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, P.O. Box 30.001, NL-9700 RB, Groningen, The Netherlands
| | - John HJM Meertens
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, P.O. Box 30.001, NL-9700 RB, Groningen, The Netherlands
| | - Jan G Zijlstra
- Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, P.O. Box 30.001, NL-9700 RB, Groningen, The Netherlands
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Zijlstra JG, Corstjens AM, Tulleken JE, Meertens JHJM, Ligtenberg JJM. Cost analysis of intensive glycemic control in critically ill adult patients. Chest 2007; 130:1953-4. [PMID: 17167028 DOI: 10.1378/chest.130.6.1953a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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van Oers JAH, Tulleken JE, Zijlstra JG. Does serum procalcitonin have a diagnostic value in febrile adult patients presenting to the emergency department? Crit Care 2007; 11:422; author reply 422. [PMID: 18086319 PMCID: PMC2246205 DOI: 10.1186/cc6172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Ligtenberg JJ, Monteban-Kooistra WE, Meertens JH, Tulleken JE, Zijlstra JG. The ACTH test should not be used in the decision to start low dose steroids in catecholamine-dependent septic shock. Intensive Care Med 2006; 33:551. [PMID: 17165014 DOI: 10.1007/s00134-006-0490-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2006] [Indexed: 11/29/2022]
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Meijering S, Corstjens AM, Tulleken JE, Meertens JHJM, Zijlstra JG, Ligtenberg JJM. Towards a feasible algorithm for tight glycaemic control in critically ill patients: a systematic review of the literature. Crit Care 2006; 10:R19. [PMID: 16469124 PMCID: PMC1550808 DOI: 10.1186/cc3981] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2005] [Revised: 12/22/2005] [Accepted: 01/03/2006] [Indexed: 01/04/2023]
Abstract
Introduction Tight glycaemic control is an important issue in the management of intensive care unit (ICU) patients. The glycaemic goals described by Van Den Berghe and colleagues in their landmark study of intensive insulin therapy appear difficult to achieve in a real life ICU setting. Most clinicians and nurses are concerned about a potentially increased frequency of severe hypoglycaemic episodes with more stringent glycaemic control. One of the steps we took before we implemented a glucose regulation protocol was to review published trials employing insulin/glucose algorithms in critically ill patients. Methods We conducted a search of the PubMed, Embase and Cochrane databases using the following terms: 'glucose', 'insulin', 'protocol', 'algorithm', 'nomogram', 'scheme', 'critically ill' and 'intensive care'. Our search was limited to clinical trials conducted in humans. The aim of the papers selected was required to be glycaemic control in critically ill patients; the blood glucose target was required to be 10 mmol/l or under (or use of a protocol that resulted in a mean blood glucose = 10 mmol/l). The studies were categorized according to patient type, desired range of blood glucose values, method of insulin administration, frequency of blood glucose control, time taken to achieve the desired range for glucose, proportion of patients with glucose in the desired range, mean blood glucose and frequency of hypoglycaemic episodes. Results A total of twenty-four reports satisfied our inclusion criteria. Most recent studies (nine) were conducted in an ICU; nine others were conducted in a perioperative setting and six were conducted in patients with acute myocardial infarction or stroke. Studies conducted before 2001 did not include normoglycaemia among their aims, which changed after publication of the study by Van Den Berghe and coworkers in 2001; glycaemic goals became tighter, with a target range between 4 and 8 mmol/l in most studies. Conclusion Studies using a dynamic scale protocol combining a tight glucose target and the last two blood glucose values to determine the insulin infusion rate yielded the best results in terms of glycaemic control and reported low frequencies of hypoglycaemic episodes.
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Affiliation(s)
- Sofie Meijering
- Medical Doctor, Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, Groningen, The Netherlands
| | - Anouk M Corstjens
- Anesthesiologist, Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, Groningen, The Netherlands
| | - Jaap E Tulleken
- Internist-intensivist, Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, Groningen, The Netherlands
| | - John HJM Meertens
- Anesthesiologist-intensivist, Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Internist-intensivist, Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, Groningen, The Netherlands
| | - Jack JM Ligtenberg
- Internist-intensivist, Intensive & Respiratory Care Unit (ICB), University Medical Center Groningen, Groningen, The Netherlands
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Ligtenberg JJM, Meertens JH, Monteban-Kooistra WE, Tulleken JE, Zijlstra JG. Multicentric, randomized, controlled trial to evaluate blood glucose control by the model predictive control algorithm versus routine glucose management protocols in intensive care unit patients: Response to Plank et al. Diabetes Care 2006; 29:1987. [PMID: 16873825 DOI: 10.2337/dc06-0732] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Nieuwenhuis JA, Meertens JHJM, Zijlstra JG, Ligtenberg JJM, Tulleken JE, van der Werf TS. Automated erythrocytapheresis in severe falciparum malaria: A critical appraisal. Acta Trop 2006; 98:201-6. [PMID: 16765312 DOI: 10.1016/j.actatropica.2006.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Revised: 05/04/2006] [Accepted: 05/05/2006] [Indexed: 11/18/2022]
Abstract
Imported falciparum malaria is increasing in Western countries. In patients with severe disease, exchange transfusion has been added to antimalarial and conventional supportive therapy to increase removal of parasitized erythrocytes, but hemodynamic compromise limits its use; automated erythrocytapheresis may be advantageous. We review published reports of patients with severe falciparum malaria treated by automated erythrocytapheresis combined with standard therapy and add three more cases to the literature. No studies have been conducted to evaluate its clinical efficacy, and this adjunct therapy should therefore be considered as salvage therapy. Apheresis of red cells appears feasible, safe and effective in rapidly reducing parasite count.
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Affiliation(s)
- Jellie A Nieuwenhuis
- Intensive and Respiratory Care Unit, Department of Internal Medicine, Groningen University Medical Centre, University of Groningen, The Netherlands
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Corstjens AM, van der Horst ICC, Zijlstra JG, Groeneveld ABJ, Zijlstra F, Tulleken JE, Ligtenberg JJM. Hyperglycaemia in critically ill patients: marker or mediator of mortality? Crit Care 2006; 10:216. [PMID: 16834760 PMCID: PMC1550943 DOI: 10.1186/cc4957] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute hyperglycaemia has been associated with complications, prolonged intensive care unit and hospital stay, and increased mortality. We made an inventory of the prevalence and prognostic value of hyperglycaemia, and of the effects of glucose control in different groups of critically ill patients. The prevalence of hyperglycaemia in critically ill patients, using stringent criteria, approaches 100%. An unambiguous negative correlation between hyperglycaemia and mortality has been described in various groups of critically ill patients. Although the available evidence remains inconsistent, there appears to be a favourable effect of glucose regulation. This effect on morbidity and mortality depends on patient characteristics. To be able to compare results of future studies involving glucose regulation, better definitions of hyperglycaemia (and consequently of normoglycaemia) and patient populations are needed.
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Affiliation(s)
- Anouk M Corstjens
- Department of Anaesthesiology, Intensive & Respiratory Care Unit, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan CC van der Horst
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Intensive & Respiratory Care Unit, University Medical Center Groningen, Groningen, The Netherlands
| | - AB Johan Groeneveld
- Department of Intensive Care, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jaap E Tulleken
- Intensive & Respiratory Care Unit, University Medical Center Groningen, Groningen, The Netherlands
| | - Jack JM Ligtenberg
- Intensive & Respiratory Care Unit, University Medical Center Groningen, Groningen, The Netherlands
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Top LJ, Tulleken JE, Ligtenberg JJM, Meertens JHJM, van der Werf TS, Zijlstra JG. Serious envenomation after a snakebite by a Western bush viper (Atheris chlorechis) in the Netherlands: a case report. Neth J Med 2006; 64:153-6. [PMID: 16702615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Venomous snakebites are a rarity in the Netherlands. In this report we describe the case of a 26-year-old male amateur snakekeeper who was bitten in his left index finger by a Western bush viper (Atheris chlorechis). His clinical condition deteriorated rapidly with acute renal failure and considerable blood loss due to coagulopathy. Antidote was not readily available and was finally supplied by a zoo in Antwerp, Belgium. One day after admission the blood loss diminished.
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Affiliation(s)
- L J Top
- Intensive and Respiratory Care Unit, Department of Internal Medicine, University Medical Centre Groningen, Groningen, the Netherlands.
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Abstract
We describe the cases of two patients discharged home directly from the ICU. Both patients had the strong wish to die at home after being told that there were no therapeutic options. Sometimes discharge is feasible and can mean very much for patients and their family. Taking measures to ensure a "good deathbed" is an obligation for doctors and nursing staff. However, due to the focus on cure this palliative goal is not always pursued.
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Affiliation(s)
- Brigitte C Beuks
- Intensive and Respiratory Care, Department of Internal Medicine, University Medical Centre Groningen, University of Groningen, 30.001, 9700 RB, Groningen, The Netherlands
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Ligtenberg JJM, Meijering S, Stienstra Y, van der Horst ICC, Vogelzang M, Nijsten MWN, Tulleken JE, Zijlstra JG. Mean glucose level is not an independent risk factor for mortality in mixed ICU patients. Intensive Care Med 2006; 32:435-8. [PMID: 16477415 DOI: 10.1007/s00134-005-0052-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 12/19/2005] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To find out if there is an association between hyperglycaemia and mortality in mixed ICU patients. DESIGN AND SETTING Retrospective cohort study over a 2-year period at the medical ICU of a university hospital. MEASUREMENTS Admission glucose, maximum and mean glucose, length of stay, mortality, insulin therapy and Apache-II score. RESULTS In 1085 consecutive patients, ICU- and hospital mortality were 20 and 25%, respectively. The total number of blood glucose measurements was 10.012. Admission glucose was 7.9 +/- 4.5 mmol/l (mean +/- SD), mean glucose 7.5 +/- 2.9 and maximum glucose 10.0 +/- 5.4 mmol/l. Median ICU length of stay (LOS) was 3.0 days (range 2.0-6.0 days, IQR), and hospital LOS was 16 days (range 7-32 days). In 28% of patients insulin treatment was started. Median Apache-II score was 13. 68% of patients were mechanically ventilated. Univariate analysis showed an association with ICU mortality for mean glucose (non-survivors 8.6 +/- 4.3 vs 7.2 +/- 2.4 survivors), maximum glucose (11.7 +/- 5.9 vs 9.6 +/- 5.2, non-survivors vs survivors, respectively), use of insulin (mortality 29 vs 17% in patients not using insulin) and age (61 vs 55.7 years). Gender and a history of diabetes mellitus were not associated with mortality. In a multivariate model, the Apache-II score was the only variable associated with mortality independent of other variables, including mean blood glucose. CONCLUSION In this retrospective study mean glucose level was not an independent risk factor for mortality in mixed ICU patients.
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Affiliation(s)
- Jack J M Ligtenberg
- University Medical Centre Groningen, Intensive and Respiratory Care Unit (ICB), 30.001, 9700 RB, Groningen, The Netherlands.
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Monteban-Kooistra WE, van den Berg MP, Tulleken JE, Ligtenberg JJM, Meertens JHJM, Zijlstra JG. Brugada electrocardiographic pattern elicited by cyclic antidepressants overdose. Intensive Care Med 2006; 32:281-285. [PMID: 16432670 DOI: 10.1007/s00134-005-0007-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2005] [Accepted: 11/09/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The Brugada syndrome is a clinical and electrocardiographic familial entity, which may lead to sudden cardiac death. A Brugada pattern ECG may occasionally be caused by conditions such as an overdose of tricyclic antidepressants (TCA). Toxicity of TCA frequently results in the need for critical care support. We retrospectively studied characteristics and electrocardiographic indicators of toxicity of all TCA poisoned patients. SETTING All patients admitted from 1/1/2000 to 1/11/2004 to our ICU after an act of deliberate self-poisoning were included. The ECG's were analysed retrospectively by a cardiologist. Patients with an overdose of TCA were divided in three groups; I. without ECG abnormalities, II. Presence of ECG abnormalities but without Brugada signs, III patients with a Brugada pattern ECG. RESULTS 134 patients were admitted. In 35 patients a TCA was the main toxic substance. In 12 (34%) TCA patients no ECG abnormalities were found. An increase in QRS duration (>100 ms) was seen in 13 (37%) cases. Six (17%) of them demonstrated a Brugada like pattern. The ECG abnormalities resolved quickly after administration of sodium bicarbonate. Length of stay did not differ between groups. APACHE II and the amount of sodium bicarbonate administered were the highest in the Brugada pattern group. Two patients died. CONCLUSIONS in TCA poisoning the Brugada pattern ECG is a particular manifestation of the frequently occurring intraventricular conduction disturbances. In intoxicated patients in whom the substance is unknown early recognition of the conduction disturbances is important for suspecting a poisoning with TCA.
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Affiliation(s)
- Wilma E Monteban-Kooistra
- Intensive & Respiratory Care Unit (ICB), Dept. Cardiology, University Medical Center Groningen, 30.001, 9700 RB, Groningen, Netherlands
| | - Maarten P van den Berg
- Intensive & Respiratory Care Unit (ICB), Dept. Cardiology, University Medical Center Groningen, 30.001, 9700 RB, Groningen, Netherlands
| | - Jaap E Tulleken
- Intensive & Respiratory Care Unit (ICB), Dept. Cardiology, University Medical Center Groningen, 30.001, 9700 RB, Groningen, Netherlands.
| | - Jack J M Ligtenberg
- Intensive & Respiratory Care Unit (ICB), Dept. Cardiology, University Medical Center Groningen, 30.001, 9700 RB, Groningen, Netherlands
| | - John H J M Meertens
- Intensive & Respiratory Care Unit (ICB), Dept. Cardiology, University Medical Center Groningen, 30.001, 9700 RB, Groningen, Netherlands
| | - Jan G Zijlstra
- Intensive & Respiratory Care Unit (ICB), Dept. Cardiology, University Medical Center Groningen, 30.001, 9700 RB, Groningen, Netherlands
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Hanekamp BB, Zijlstra JG, Tulleken JE, Ligtenberg JJM, van der Werf TS, Hofstra LS. Serotonin syndrome and rhabdomyolysis in venlafaxine poisoning: a case report. Neth J Med 2005; 63:316-8. [PMID: 16186642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Newer, more selective, antidepressant agents are increasingly being used as first-line treatment. However, clinical experience in patients after a deliberate overdose is limited. We present a case of venlafaxine intoxication complicated by a late rise in creatine kinase, seizures and serotonin syndrome. Rhabdomyolysis prolonged the hospital stay in our patient but had no other serious consequences. Physicians should be aware of this late phenomenon in patients with venlafaxine poisoning.
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Affiliation(s)
- B B Hanekamp
- Intensive and Respiratory Care, Groningen University Medical Centre, Groningen, the Netherlands.
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van Bockel EAP, Tulleken JE, Ligtenberg JJM, van der Werf TS, Aarts LPHJ, Zijlstra JG. [The significance of elevated troponin levels in the absence of acute cardiac ischaemia]. Ned Tijdschr Geneeskd 2005; 149:1879-83. [PMID: 16136740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Cardiac troponin I (cTnI) and cardiac troponin T (cTnT) are valuable heart markers in patients presenting with symptoms of ischaemic heart disease. A number of categories of patients frequently have raised concentrations of cardiac troponin (cTn) without having ischaemic heart disease. These include patients with heart diseases such as heart failure, myocarditis and valvular disease but also those with lung emboli, renal failure and sepsis. Possible underlying mechanisms are diffuse necrosis, cTn proteolysis or leakage of cytoplasmatic cTn with no irreversible damage to the contraction complex of heart-muscle cells. It is possible that cTn-measurement in patients with non-cardiac conditions is of prognostic value but so far this has only been demonstrated in dialysis patients and patients with pulmonary embolism.
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Affiliation(s)
- E A P van Bockel
- Universitair Medisch Centrum Groningen, Afd. Anesthesiologie, Groningen.
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Ligtenberg JJM, Meijering S, Vogelzang M, Nijsten MWN, van der Horst ICC, Tulleken JE, Zijlstra JG. Relationship of baseline glucose and mortality during medical critical illness? Chest 2005; 127:2283. [PMID: 15947353 DOI: 10.1378/chest.127.6.2283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Ligtenberg JJM, Arnold LG, Stienstra Y, van der Werf TS, Meertens JHJM, Tulleken JE, Zijlstra JG. Quality of interhospital transport of critically ill patients: a prospective audit. Crit Care 2005; 9:R446-51. [PMID: 16137359 PMCID: PMC1269465 DOI: 10.1186/cc3749] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Revised: 05/23/2005] [Accepted: 06/02/2005] [Indexed: 12/24/2022]
Abstract
Introduction The aim of transferring a critically ill patient to the intensive care unit (ICU) of a tertiary referral centre is to improve prognosis. The transport itself must be as safe as possible and should not pose additional risks. We performed a prospective audit of the quality of interhospital transports to our university hospital-based medical ICU. Methods Transfers were undertaken using standard ambulances. On departure and immediately after arrival, the following data were collected: blood pressure, heart rate, body temperature, oxygen saturation, arterial blood gas analysis, serum lactic acid, plasma haemoglobin concentration, blood glucose, mechanical ventilation settings, use of vasopressor/inotropic drugs, and presence of venous and arterial catheters. Ambulance personnel completed forms describing haemodynamic and ventilatory data during transport. Data were collected by our research nurse and analyzed. Results A total of 100 consecutive transfers of ICU patients over a 14-month period were evaluated. Sixty-five per cent of patients were mechanically ventilated; 38% were on vasoactive drugs. Thirty-seven per cent exhibited an increased number of vital variables beyond predefined thresholds after transport compared with before transport; 34% had an equal number; and 29% had a lower number of vital variables beyond thresholds after transport. The distance of transport did not correlate with the condition on arrival. Six patients died within 24 hours after arrival; vital variables in these patients were not significantly different from those in patients who survived the first 24 hours. ICU mortality was 27%. Adverse events occurred in 34% of transfers; in 50% of these transports, pretransport recommendations given by the intensivist of our ICU were ignored. Approximately 30% of events may be attributed to technical problems. Conclusion On aggregate, the quality of transport in our catchment area carried out using standard ambulances appeared to be satisfactory. However, examination of the data in greater detail revealed a number of preventable events. Further improvement must be achieved by better communication between referring and receiving hospitals, and by strict adherence to checklists and to published protocols. Patients transported between ICUs are still critically ill and should be treated as such.
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Affiliation(s)
- Jack JM Ligtenberg
- Internist-intensivist, Intensive and Respiratory Care Unit (ICB), Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - L Gert Arnold
- Intensive Care Nurse, Intensive and Respiratory Care Unit (ICB), Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Ymkje Stienstra
- Senior resident, Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Tjip S van der Werf
- Pulmonologist-intensivist, Intensive and Respiratory Care Unit (ICB), Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - John HJM Meertens
- Anesthesiologist-intensivist, Intensive and Respiratory Care Unit (ICB), Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Jaap E Tulleken
- Internist-intensivist, Intensive and Respiratory Care Unit (ICB), Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Internist-intensivist, Intensive and Respiratory Care Unit (ICB), Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
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Regtien JG, Stienstra Y, Ligtenberg JJM, van der Werf TS, Tulleken JE, Zijlstra JG. Morbidity in hospitalized patients receiving human albumin: a meta-analysis of randomized, controlled trials. Crit Care Med 2005; 33:915; author reply 915-7. [PMID: 15818137 DOI: 10.1097/01.ccm.0000159933.47466.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van der Werf TS, Zijlstra JG, Ligtenberg JJM, Tulleken JE. [Decisions around the end of life on Intensive Care: making the transition from curative to palliative treatment]. Ned Tijdschr Geneeskd 2005; 149:742-6. [PMID: 15835624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The decision to move from curative treatment to palliative care in the intensive-care situation is less related to morals and ethics than it is to the assessment of medical issues, professionalism, communication and orchestration. Treatment should be considered medically pointless if, in the view of the treating physicians, it does not offer realistic chance to return to a meaningful life. Continuing futile care can be seen as disrespectful, both to the patient, his partner and the family, as well as to the members of the ICU team. Intensivists are responsible for withholding or withdrawing life support to patients in whom further life support is considered futile and who are unable to express their wishes due to critical illness and sedation. The intensivist typically makes this type of decision after a period in which medical and other information has been collected and after intensive discussions with other medical professionals as well as the partner and family. This is based on the trust that is built up through their skill, attitude and behaviour and that is perpetuated in a continuing process of intensive communication. Conflicts should be prevented, or at least recognised early and discussed. Ifa conflict is ongoing then it should be tackled by planning a number of consecutive consultations.
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Affiliation(s)
- T S van der Werf
- Universitair Medisch Centrum Groningen, afd Interne Geneeskunde, 9700 RB Groningen.
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