Children Sedated in ICU Often Experience Scary Hallucinations

Children who received sedative drugs while in the PICU often have frightening delusions or
hallucinations which can cause lingering trauma. A new report published this week examines the
experiences of children who have been in the PICU (Pediatric Intensive Care Unit) and received
sedative drugs during their stay.
The report, published in this week’s issue of The American Journal of Respiratory and Critical Care
Medicine, says that almost a third of children sedated while in the PICU experienced vivid,
frightening hallucinations that they clearly remembered later. The study’s researchers asked children
between the ages of 7 and 17 about their memories of their intensive-care stay, three months after
their discharge. Most of the children remembered some factual information and occurrences, such as
a visit from a family member. Thirty-two percent of the children also reported disturbing, scary
hallucinations. "In the majority of cases, these delusional memories consisted of one or more
hallucinations which were often frightening and which the children could still recall vividly," said lead
author Gillian Colville, a clinical psychologist and head of the pediatric psychology department at
London’s St. George's Hospital. "They reported seeing rats, cats, scorpions on the walls and, in some
cases, crawling on the bed, and a couple of children were convinced that their parents had been
replaced by imposters."
The more days the children were sedated, the more likely they were to have experienced this type
of scary hallucination.
Children who received opiates or drugs in the benzodiazepine family such as Valium for more than
two days were five times as likely as the other children to have visual, auditory, or tactile
hallucinations.

The children who’d experienced the delusions were also those who scored the highest on post-
traumatic stress screening tests, and it was their memories of the hallucinations that troubled them
most, not the actual experience of being in the ICU.

"These findings are interesting because it has been assumed that the actual experiences in the PICU
would be more likely to lead to posttraumatic stress symptoms following discharge," stated Colville
in a press release. "However, our results indicate that posttraumatic stress symptoms are associated
with delusional memories rather than factual ones." The timing of the hallucinations coincided with
when the children were being taken off of the sedative drugs.

Colville says she was interested in studying children’s experiences because, while it is well known
that adults sometimes have hallucinations under sedation, there had not been any major studies
looking at the reactions of children to the same drugs.

"I have worked for 16 years in pediatric intensive care and have seen a considerable number of
children in distress," said Colville. "But [I] have found that there is very little in the literature about
children's experiences."

The study is considered important because it could change the way intensive-care physicians use
sedative drugs on their young patients. Hospitals may consider a technique known as "drug vacation,"
in which patients are given brief respites from continuous sedation. Or they may decide to wean
patients off of the drugs more slowly, to hopefully reduce the frequency of frightening
hallucinations.

Colville says the important thing is that hospitals be made aware of children’s reactions to better
handle their emotional responses to sedative drugs.
Said Colville, "…above all, medical professionals and families should be made aware of the possibility
that children may have these disturbing hallucinatory experiences, and greater efforts should be
made to monitor their psychological adjustment after PICU."

Reaction

We as a student nurse are aware that hallucination is one of the types of a Psychological disorder
which is the Schizophrenia. Hallucinations are false or distorted sensory experiences that appear to
be real perceptions. These sensory impressions are generated by the mind rather than by any
external stimuli, and may be seen, heard, felt, and even smelled or tasted. In this article, most of
the patient who admitted in the Pediatric Intensive Care Unit are experiencing this type of
psychological disorder. As what I’ve read in this article, it might be the side effect of the drugs that
they might take. Because some of the drugs have a side effects of being dizzy or drowsy. So as I
analyze the article, the brains of the pedia are not well functioning during the illness, so if there are
not well functioning and they are taking drugs who have side effects which are related to the
function of the brain. There are possibilities that the patient may develop mental disorder.
Additionally in the article, it said that one of the reasons why pediatric patients are experiencing
hallucination is the post traumatic stress symptoms which are associated with delusional memories
rather than factual ones.

No intensive care for burns

Garment worker Sumi, 28, who struggled for 18 days with burn injures sustained in a collision
between a bus and an acid-laden truck on Dhaka-Chittagong highway in Comilla on November 6, died
without receiving intensive care.

As the Burn and Plastic Surgery Unit of Dhaka Medical College Hospital (DMCH) has no operational
Intensive Care Unit (ICU), critical burn patients like Sumi, Faysal and others had to die without
receiving the care they deserved. About 15 patients out of 190 receiving treatment at the unit need
intensive care, said hospital authorities.

“Those who receive 40 to 60 percent burns in their bodies require intensive care. Unfortunately we
are yet to make the eight-bed ICU operational at the burn unit despite having modern equipment and
funding,” said Shamantalal Sen, project director of the unit.

Equipment worth more than Tk 2 crore has been lying idle at the ICU since its inception in 2003. The
authorities failed to run the well-equipped ICU in five years due to lack of manpower. The ICU is
equipped with ventilator, Pulse Oxymeter, cardiac monitor and blood analyzer. This forces financially
solvent patients to move to private hospitals. “We tried to run the ICU twice as we receive three to
four patients every day who need intensive care. In ICU every patient should have a nurse dedicated
to him or her. We do not have enough manpower for general beds even, how we can run the ICU with
such an insignificant number of nurses and doctors?” said Shamantalal.

In 2005, the ICU ran for eight months and in 2006 it ran for two months and then its operation was
suspended as the authorities failed to employ doctors and nurses. The critically injured patients have
been kept in the Dependency Unit instead.

According to the experts, one nurse is needed for every five burn patients and the country’s lone
burn management centre only has 30 nurses and they have to take care of around 190 burn patients
every day on an average. Those 30 nurses cannot work 24/7, they work in shifts which widens the
patient nurse ratio.

Around eight doctors were brought in at the ICU primarily on deputation. A few of them left and
others are attending emergency patients. No class four employees were recruited there, said the
project director adding that currently around 30 people are providing casual labor in the 50-bed burn
unit.

“We might not save the lives of critical patients but at least we could have the consolation that we
tried our best,” said Assistant Registrar of the unit Kishore Kumar Das adding that a burn unit without
an ICU is quite unimaginable and all developed countries have an ICU at their burn units.

Experts say that due to the absence of an ICU, the doctors of the burn unit have been deprived of
gathering experience on intensive care management. They cannot think about providing aggressive
treatment to seriously injured patients and at the same time the absence of an ICU hinders adopting
early excision protocol, in which the burned tissues are removed from the body within five days of
injury.

Effort should be made by all to develop the centre which currently is acting as the lone shelter for
burn patients across the country, the authorities said. A highly-placed source said, “We do not want
the costly equipment to get ruined due to lack of use when patients need the support badly.

Talking to The Daily Star the authorities also said the unit was established under a project and as it is
yet to be moved to the revenue sector, they have been facing problems in recruiting manpower.

“However, process is going on to transfer the project to the revenue sector and we would be able to
recruit manpower for 100 beds soon after the project is transferred,” said the project director.

Reaction

This article talks about the problems of their hospital. Their hospitals are not fully equipped. They
have problems with the materials or equipment that will be needed in caring patients. Just like the
15 patient who suffered from burn injuries. Those patients do not receive a treatment that they
should have in the intensive care unit. Shamantalal Sen said that they unable to afford of the needs
of those patient. They are lack of bed and other modern equipment. With those reasoning, many of
the patients died. One of the staff said that “they might not save the lives of critical patients but at
least we could have the consolation that we tried our best,” My reaction to this article is that,
before building a hospital, they should plan everything. All the necessary equipment should be
available. Because hospitals are institutions in which illnesses, injuries, and disabilities are diagnosed
and treated. Hospitals are capable of providing medical services beyond those available in physicians'
offices or outpatient facilities. In hospital settings, aseptic technique should be perform to prevent
further complication that the patient might experience.
 ICU-Based Interventions May Reduce Vancomycin Use
Kate Traynor

BETHESDA, MD, 20 August 2002. A study led by researchers at the Centers for Disease Control and
Prevention indicates that specific actions in the intensive care unit (ICU) to limit the use of
vancomycin work better than hospital wide strategies.

By studying vancomycin use at 50 ICUs in 20 hospitals, the research team found that hospital wide
intervention programs—drug-use evaluation, specific approval of a vancomycin order before
dispensing, and the distribution of a national guideline on preventing the spread of vancomycin-
resistant enterococci (VRE)—had virtually no effect on the amount of the agent used in the units.

But one ICU-based intervention, the discontinuation of routine prophylaxis with vancomycin for
cardiac surgery, decreased use of the drug by an average of 45 percent at the three ICUs that
instituted the new practice. In contrast, vancomycin use was essentially unchanged at the ICUs that
did not eliminate routine vancomycin prophylaxis for cardiac surgery.

Likewise, at the nine ICUs that established unit-specific educational programs describing the
appropriate prescribing of vancomycin, use of the drug fell an average of 27 percent by the end of
the 3.5-year study. These ICUs had initially used far more of the drug—an average of 132 daily doses
of vancomycin per 1,000 patient-days—than did the other ICUs, which averaged 76 daily doses per
1,000 patient-days.

At ICUs that did not set up a specific educational program, vancomycin use rose an average of 10
percent but remained slightly lower than at ICUs that had undertaken such a program. The study's
findings were reported in the July issue of Emerging Infectious Diseases.

Interventions in the ICUs appeared to affect the emergence of resistant bacteria. The prevalence of
VRE decreased by 8 percent on average in ICUs that changed their unit-specific practice but rose 6
percent at the other ICUs.

After adjusting the data to reflect differences in the prevalence of methicillin-resistant

Staphylococcus aureus, the research team concluded that interventions targeted at ICUs cut the use
of vancomycin by an average of 49 daily doses per 1,000 patient-days.

Hospitals that participated in the study were part of Project Intensive Care Antimicrobial Resistance
Epidemiology, a surveillance and benchmarking program designed to drive practice changes that slow
the spread of antimicrobial resistance. Midway through the project, the hospitals were sent local and
national benchmarking data on vancomycin use. Surveys were conducted at the end of the study to
determine how the hospitals used the benchmarking data and whether the resulting interventions
affected vancomycin prescribing.

The research team concluded that hospitals, by comparing local antimicrobial-monitoring data and
national benchmarking data, can determine whether practice changes are needed to reduce the use
of an antimicrobial agent.

Funding for the study was provided by the ASHP Research and Education Foundation and several
other nonprofit and commercial organizations.
Reaction

This article talks about the limitation in using some drugs. This issue talks the antimicrobial drug
which is the vencomycin. You can read in the last part of the article that researchers are comparing
the local antimicrobial-monitoring data and national benchmarking data. The vancomycin used to
treat certain kinds of bacterial infections and prophylaxis. It will not work for colds, flu, or other
viral infections. In taking these drugs, first thing to do is to have the patient a skin test. To be check
if the patient has an allergic reaction with this kind of drugs. So in the intensive care unit, they are
implementing to limit the use of this drug. Maybe because this drug does not effective with some
surgery like in cardiac surgery. But unfortunately, not all of the hospitals are following this rule. So
they decide to conduct first a research with this drug.

In the ICU, Use of Benzodiazepines, Other Factors May Predict

Severity of Post-Stay Depression

April 10, 2009- Psychiatrists and critical care specialists at Johns Hopkins have begun to tease out
what there is about a stay in an intensive care unit (ICU) that leads so many patients to report
depression after they go home.

In a study reported online April 10 in Critical Care Medicine, the Hopkins researchers say several
factors predicted symptoms of depression six months after hospitalization among very sick ICU
patients, including a high level of organ failure and being given relatively high doses of a
benzodiazepine sedative.

“The hope is that as we learn more about the effect of variations in ICU care, we’ll be able to
predict which patients are most susceptible to depression, prevent some depression by changing ICU
practices, and make sure patients receive adequate mental health monitoring after discharge,” says
O. Joseph Bienvenu, M.D., Ph.D., an associate professor in the Department of Psychiatry at the Johns
Hopkins University School of Medicine.

Bienvenu says doctors have long theorized that a health problem devastating enough to send
someone to an ICU might well trigger depression, but because only some patients become depressed,
he and his colleagues wondered whether the root causes might be more complex.

“Historically, the only goal for critical care physicians, understandably, was to keep people alive, but
now there is interest in longer-term outcomes, such as patients’ mental health and well-being,” says
Bienvenu. “So we asked ourselves, could certain aspects of critical illness and ICU care swing
patients toward depression?”

To test the idea, Bienvenu and other Johns Hopkins researchers evaluated patients recently admitted
to one of 13 ICUs located at four teaching hospitals in Baltimore, Md., including four ICUs at The
Johns Hopkins Hospital.

Each of the patients was treated for acute lung injury (ALI), a respiratory distress syndrome that’s
considered an archetype of critical illness. Patients with ALI typically require invasive interventions
in the ICU, including use of ventilators. Though better care has greatly reduced mortality rates, ALI
still kills about 40 percent of those affected.
Bienvenu and his colleagues followed 160 patients who had survived at least six months after their
ALI diagnosis. The researchers took note of a variety of features of each patient’s status and care
while in the ICU, such as severity of organ failure, their blood sugar levels and other lab work, and
the amount and type of sedative they received.

At six months after ALI diagnosis, the researchers administered a questionnaire to patients that
measured depressive symptoms ranging from none to possible or probable clinical depression. Of the
160, 26 percent scored above the threshold for possible depression. Compared to other ALI survivors,
the depressed patients were more likely to have suffered greater severity of organ failure and to
have received 75 mg or more of a benzodiazepine sedative daily.

Bienvenu says that because more severe organ failure may lead to a longer physical recovery period
after ICU discharge, patients’ depression may be explained, in part, by a slow recovery. However, he
and his colleagues aren’t sure how to explain the association between depression and ICU
benzodiazepine dose.

Reaction

Just like the other article, this articles talks about the use of benzodiazepine drug as sedative. They
said that most of the patients who are already discharge are suffering to depression. Especially those
patients with critical illness in ICU. Most patients are administering a high dose of benzodiazepine.
That’s the reason why their organs are damaged. One possibility could be that the amount of this
drug received reflects how agitated patients were in the ICU, with very distressed individuals getting
higher doses. However, because this relationship hasn’t been seen with other types of sedatives
commonly prescribed in the ICU, it’s possible that high doses of benzodiazepine alone may somehow
cause depressive symptoms. To prevent the depression after hospitalization, patient should take only
the prescribed dose of benzodiazepine because it can be addicted.

Study to change how critically ill patients treated across the world

Internationally, intensive blood glucose lowering has been widely recommended and embraced to control
hyperglycemia (high blood sugar) which is extremely common among acutely ill patients and linked with
serious complications such as organ failure and death.

Local researchers were concerned with this treatment strategy and decided to conduct a large,
landmark trial to confirm the best treatment for critically ill patients. These new findings reveal that
international practice to intensively lower blood glucose actually increases the risk of death among
intensive care unit (ICU) patients.

"Intensively lowering blood glucose in critically ill patients is not beneficial and may be harmful. Based
on our findings, we do not recommend pursuing a normal blood glucose level in critically ill patients. We
found that intensively lowering blood glucose levels increased a patient's risk of dying by 10 per cent,"
said Chief Investigator, Professor Simon Finfer from the Faculty of Medicine and the University George
Institute for International Health.
Researchers from The Australian and New Zealand Intensive Care Society Clinical Trials Group, The
George Institute for International Health, The Canadian Critical Care Trials Group and Vancouver Coastal
Health Research Institute set out to clarify the target range for blood glucose levels in critically ill
patients. They followed 6104 ICU patients in Australia, New Zealand, Canada and the USA for up to 90
days to assess whether the treatment would improve patients chance of survival.

"Previous, smaller research studies have produced conflicting results and overall suggested that intensive
blood glucose control didn't affect death rates in critically ill adults. This new study gives us more
powerful information, based on this larger study with stronger evidence, we can conclude that targeting
very low levels of blood glucose is not safe," said Professor John Myburgh from The University of Sydney's
George Institute for International Health.

In Australia over 125,000 people are admitted to ICUs each year and around 7,500 patients die in
Australian ICUs each year. In New Zealand, every year 17,500 people are admitted to ICUs with around
1,200 patients dying. The new evidence suggests that current guidelines must be reviewed.

"It's essential that international guidelines reflect this new evidence. Many professional organizations
recommend very tight glucose control for ICU patients - they will now need to take this new evidence
into consideration and adjust recommendations accordingly," said New Zealand researcher Dr. Colin
McArthur, Auckland City Hospital.

Commenting on the findings, co-author and Dean of the Faculty of Medicine, Professor Bruce Robinson,
said: "Running this study across a large patient group in a number of different countries has been a
mammoth effort for clinicians and researchers, and Professor Finfer and colleagues should be
congratulated on their achievements. In finding that clinical care guidelines need to be urgently
reviewed, they have provided a clear example of how high quality research directly improves patient
care."

The study, NICE-SUGAR (Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose
Algorithm Regulation) randomly assigned patients to one of two target ranges for blood glucose; an
intensive control target (81-108mg/dL; 4.5-6.0 mmol/L) or a conventional control target (180mg/dL;
10.0 mmol/L or less). Control of blood glucose was achieved by the use of an intravenous infusion of
insulin.

Reaction

This is all about the effect of increase and decreased amount of insulin inside the body of a patient who
are critically ill especially those are admitted in the Intensive Care Unit. Let me give you an idea on
what is insulin is. Insulin is a hormone that regulates the amount of glucose (sugar) in the blood and is
required for the body to function normally. Certain cells in the body change the food ingested into
energy, or blood glucose, that cells can use. Every time a person eats, the blood glucose rises. So in this
article they said that people should lower their insulin level to prevent hyperglycemia. But in the
hospital settings, staff nurses should not lower the insulin level in an intensively form. Because this may
cause a further death of the patient. The level of insulin should be in its normal level. Not greater than
or less than the normal values.
 Early mobilization of patients in ICU improves outcomes
The study results will be announced on May 17 at the 105th International Conference of the American
Thoracic Society in San Diego.

"Weakness and loss of functional independence—the inability to transfer from bed, walk and execute
typical daily self-care activities, such as cleaning and dressing oneself—are commonly experienced
among patients discharged from the intensive care unit," said William Schweickert, M.D., assistant
professor of medicine in the Pulmonary, Allergy, and Critical Care Division at the University of
Pennsylvania Medical Center. "This can result in major disability and protracted rehabilitation and may
be accelerated or exacerbated by prolonged periods of immobility, especially among patients who
undergo mechanical ventilation and sedation."

"Because ICU-acquired weakness is associated with such poor outcomes and potentially exacerbated by
deep sedation and immobility, we wanted to see whether mobilization begun in the earliest days of
respiratory failure would improve patient function at hospital discharge and reduce delirium," he
continued.

Dr. Schweickert and colleagues conducted a randomized trial of 100 patients who were undergoing
sedation and mechanical ventilation in the ICU. They compared patients who underwent a protocol of
daily mobilization in conjunction with sedative interruption with those who underwent sedative
interruption alone and therapy services as ordered by their primary care team.

They found that patients who underwent the mobilization protocol were more frequently able to get out
of bed, stand and occasionally walk with assistance during mechanical ventilation. The physical regimens
prescribed by the primary care team, on the other hand, often began only after mechanical ventilation
was no longer needed, potentially leading to a longer loss of functional status and a longer recovery
time.

The degree of functional loss in the control arm was substantial—only one third of patients left the
hospital able to function independently. In contrast, nearly 60 percent of the early mobilization patients
had achieved independence.

"Overall, patients in the mobilization group were nearly twice as likely to regain their functional
independence at hospital discharge and experienced less delirium than did their counterparts who did
not receive the intervention," said Dr. Schweickert.

"The benefits of pairing mobilization and sedative interruption from the inception of critical illnesses are
substantial, but the improvements in function are not easily recognizable until about two weeks,"
observed Dr, Schweickert, adding that "starting these therapies early can be difficult in the context of
ongoing critical illness, yet the data highlights that it can be done safely. We still need to test how this
intervention and its findings translate into longer-term survival and better quality of life."

Reaction

As we all know, the entire patient inside the intensive care unit usually experience loss of consciousness
which may result to inability to move in one place to another. When the patient was not able to move,
there is a possibility that the patient will suffer another complication. In this article, researcher’s
conduct an experiment on how the patient will be less sedation and immobility. They compared 100
patient who underwent a of daily mobilization in conjunction with sedative interruption with those who
underwent sedative interruption alone and therapy services as ordered by their primary care team. As a
result of this experiment, they found out that it is more applicable to do early immobilization to prevent
the occurrence of other severe complications. Aside from the obvious and immediate health problems
that patients undergoing mechanical ventilation face, those who recover often do so with profound loss
of strength and mobility that can impair their daily functioning and even lead to increased risk of
morbidity and mortality down the line. Now research shows that functional status may be restored
earlier to ICU patients by performing daily interruptions in sedation paired with mobilization and
exercise, as led by physical and occupational therapists.

Researchers find gram-negative rods in two Philippine

neonatal intensive care units

May 15th, 2009

According to researchers, hospital acquired infections have emerged as a significant health problem in
developing areas. Neonatal mortality accounts for more than one third of all global child deaths each
year. Sepsis is a leading cause of death within the first month of life and is often acquired through
unhygienic care practices in healthcare facilities, which frequently have limited emphasis placed on
standard infection control measures.

Over a 10-month period, BUSM researchers conducted studies for colonization and bloodstream
infections with gentamicin or third generation cephalosporin-resistant GNR among all NICU infants
weekly and then on the day of discharge. Researchers found a total of 1,997 resistant GNRs colonizing
1,831 neonates. Results also showed that 376 newborns became bacteremic with a total of 437 GNRs.

The most common GNR species identified were Klebsiella, Acinetobacter, Pseudomonas aeruginosa and
Enterobacter. A high proportion of colonization and bacteremia at the two NICUs was with non-intestinal
GNRs. Factors significantly associated with increased risk of bacteremia were mechanical ventilation and
prematurity. Additionally, colonization with a resistant GNR was an independent risk factor for
bacteremia.

"Colonization with a resistant GNR was an independent risk factor for sepsis," said senior author,
Davidson Hamer, MD, associate professor of international health and medicine at Boston University
School of Public Health, and director of Boston Medical Center's Travel Clinic. "The unusually high
intensity of colonization pressure and disease with multidrug-resistant GNRs at these two NICUs
constitutes an emerging health care crisis in the developing world."

Reaction

Infection is state in which parasitic organisms attach themselves to the body, or to the inside of the
body, of another organism, causing contamination and disease in the host organism. Parasite refers
generally to any organism that lives at the expense of another organism, on which it depends for
support. The present context, we are concerned primarily with infections that relate to bacteria and
viruses. Almost all infections contracted by humans are passed along by other humans or animals. The
infection will be acquired by long duration of the certain materials inside the body. Every equipment
have their designated days on when they are just allowed to stay inside the body. in the hospital in other
country, the have found a high frequency of multidrug-resistant Gram-negative rods (GNRs) in two of the
largest neonatal intensive care units (NICUs) in the city of Manila, Philippines. Improved infection control
methods could reduce the vast number of hospital acquired neonatal infections.
 Newer ICU Ventilation Strategies Hold No Survival Benefit
HAMILTON, Ontario, Feb. 12 -- Variations on low-tidal-volume ventilation using higher positive end-
expiratory pressure (PEEP) to open the lungs of critically ill patients may have only secondary benefits,
researchers found here and in France.

An investigational strategy adding recruitment maneuvers and high levels of PEEP to established low-
tidal-volume ventilation failed to improve overall hospital mortality or barotrauma for patients with
acute lung injury, according to findings of the large Lung Open Ventilation (LOV) trial. Likewise in the
Expiratory Pressure (Express) Study, a higher level of PEEP to increase lung recruitment improved lung
function and duration of organ failure but not mortality compared with a moderate PEEP strategy aimed
at minimal distension, found Alain Mercat, M.D., of CHU d'Angers in Angers, France, and colleagues
reported in the same issue of JAMA.

The studies indicate that higher levels of PEEP are safe and probably beneficial and now need to be
tested in more selected patient populations, such as those with greater lung edema and recruitability,
they said.

The LOV trial compared the new ventilation strategy with conventional ventilation in 983 consecutive
patients at 30 ICUs in Canada, Australia, and Saudi Arabia who had acute lung injury and a ratio of
arterial oxygen tension to inspired oxygen fraction not exceeding 250. Among them, 85% met criteria for
acute respiratory distress syndrome (ARDS) at enrollment.

The 508 patients randomized to conventional ventilation were treated with target tidal volumes of 6
mL/kg of predicted body weight, plateau airway pressures not exceeding 30 cm H2O, and conventional
levels of positive end-expiratory pressure (mean 9.8 cm H2O).

The 475 participants randomized to the investigational strategy were treated with target tidal volumes
of 6 mL/kg of predicted body weight, plateau pressures not exceeding 40 cm H2O, recruitment
maneuvers using periodic hyperinflations to open collapsed lung tissue, and higher positive end-
expiratory pressures (mean 14.6 cm H2O) to prevent further collapse.

Death in the ICU, during mechanical ventilation, and during the first 28 days likewise was lower but not
significantly so with the open lung strategy (P=0.13, P=0.13, and P=0.20, respectively).

Outcomes with the investigational ventilation strategy were not proportionately better for patients with
more severe baseline lung injury, who could theoretically have benefited more.

Barotrauma was more common in the open lung ventilation group (11.2% versus 9.1% had pneumothorax,
pneumomediastinum, pneumoperitoneum, or subcutaneous emphysema, P=0.33).

However, refractory hypoxemia incidence was lower in the experimental arm (4.6% versus 10.2%, RR
0.54, P=0.01) as was death with refractory hypoxemia (4.2% versus 8.9%, RR 0.56, P=0.03).

Rescue therapy use was less common with open lung ventilation than with the conventional strategy both
among patients who met eligibility criteria (5.1% versus 9.3%, P=0.045) and overall (7.8% versus 12%,
P=0.05).

The Express study further tested strategies to control PEEP titrated by plateau pressure rather than
oxygenation. It included 767 adults with acute lung injury treated at 37 intensive care units in France.
The 382 participants randomized to a minimal distension strategy were treated with a moderate PEEP
target of 5 to 9 cm H2O (mean 8.4 cm H2O with a plateau pressure of 21.1 cm H2O).

The 385 patients randomized to an increased recruitment strategy received PEEP with a target plateau
pressure of 28 to 30 cm H2O (mean 15.8 cm H2O on day one with a plateau pressure of 27.5 cm H2O).

All patients received ventilation with a tidal volume set at 6 mL/kg of predicted body weight.

However, the increased recruitment group had more than twice as many ventilator-free days (median
seven versus three, P=0.04) and organ failure-free days (median six versus two, P=0.04) at 28 days.

The increased recruitment ventilation strategy also was associated with higher respiratory system
compliance values and better oxygenation, but modestly greater fluid requirements, which "possibly
reflected poor tolerance of higher levels of PEEP in some patients."

The lack of mortality benefit may have been because benefit for some patients was offset by harm to
others, both research groups said. In the end though, the studies support the newer ventilation
strategies as an acceptable alternative to the current standard of care, Dr. Meade and colleagues said.
Drs. Gattinoni and Caironi agreed that the findings favor use of higher levels of PEEP in the early phase
of acute lung injury and ARDS.

Until direct assessment of lung recruitability by dynamic lung imaging is widely available, they said,
"setting PEEP at the highest level compatible with a plateau pressure of 28 to 30 cm H2O and a tidal
volume of 6 mL/kg of predicted body weight seems to be a reasonable alternative."

However, another accompanying editorial by Jean-Daniel Chiche, M.D., of the University Rene Descartes
in Paris, and Derek C. Angus, M.D., M.P.H., of the University of Pittsburgh, cautioned about the unblinded
treatment in both studies.

Furthermore, "it is impossible to know whether any of these protocols outperform expert-directed
ventilator management," they noted, and inferences can be drawn only for the intervention as a whole
rather than being attributed specifically to the level of PEEP.

Reaction

Mechanical Ventilator helps a person with critical condition live more in a long duration. It is more often
use in Intensive Care Unit. This machine may help the patient breath when they are not able to breath
enough in their own. As we all know ventilator is a life saving machine but its use also has risk. It doesn’t
fix the primary disease or injury. It just helps support the patient until other treatments become
effective.in this article, they explain that the findings of these two studies may support higher PPEP
ventilation strategies despite a lack mortality benefit. In this machine, there are some complications
that the patient may experience just like the infection. Mechanical ventilation has an ET tube that will
allow the bacteria enter in the lungs which causes pneumonia. Other complication that may experience
is the collapsed of the lungs. Sometime a part of the lung that is weak may become to full of air that
starts to leak. So in using the mechanical ventilation, doctors or nurses should monitor patient who are
undergoing mechanical ventilation.
Name of Drug Classification Dosage/Frequency Route MOA Indication Nursing
Responsibility
• Before each
Generic Cardiac Inhibits the sodium- dose assess
Adult: give 0.4- IV V-fib, V-flutter,
Name: Glycosides potassium ATP phase. apical pulse for
0.6mg. Followed by CHF, pulmonary
Digoxin Promoting movement of full minute,
0.1-0.3mg q6-8hrs. edema, atrial
calcium from record and report
fibrillation and or
Brand Name: extracellular to changes in rate
flutter, and
Lanoxin intracellular cytoplasm or rhythm.
paroxysmal atrial
and strengthening • Withhold drug
contraction
myocardial contraction. and contact
provider if pulse
is < 60/min. or
>100 (adults) or
< 110/minute
(children)
• Weigh daily
• Monitor I&O and
signs of CHF

Name of Drug Classification Dosage/Frequency Route MOA Indication Nursing Responsibility

Generic Name: Decrease cardiac

Antiarrythmic and Adult: 50-100mg IV • Pulseless • Monitor EKG, BP,
Lidocaine excitability, cardiac
Anesthetic • Ventricular pulse, rhythm,
Bolus dose is contraction is
Brand Name: repeated q 3-5 mins dysarhythmias continuously.
delayed in the such as PVC’ • Monitor serum lidocaine
Xylocaine until arrythmias
subside or adverse atrium and ventricle • Ventricular levels throughout
reaction develop. tachycardia theraphy; therapreutic
• Ventricular range 1.5-5 mcg/ml
fibrillation • Monitor intake and output
• Do not mix in the same
syringe with amphoterin
B or cefazolin
• Administer Lidocaine TIV.
In case of circulatory
depression have
dopamine available.
Name of Drug Classification Dosage/ Route MOA Indication Nursing Responsibility
Frequency
• Monitor EKG, BP, pulse,
Generic Name: Decrease rhythm, continuously.
Antiarrythmic and Adult: 50-100mg IV • Pulseless
Lidocaine cardiac • Monitor serum lidocaine levels
Anesthetic • Ventricular
Bolus dose is excitability, throughout theraphy;
Brand Name: repeated q 3-5 dysarhyth
cardiac therapreutic range 1.5-5 mcg/ml
Xylocaine mins until mias such
contraction is • Monitor intake and output
arrythmias subside as PVC’
delayed in the • Ventricular • Do not mix in the same syringe
or adverse
tachycardi with amphoterin B or cefazolin
reaction develops. atrium and
a • Administer Lidocaine TIV. In
ventricle
• Ventricular case of circulatory depression
fibrillation have dopamine available.

Name of Classific Dosage/ Route MOA Indication Nursing Responsibility

Drug ation Frequency

Generic Name: Broncho Adults: For IV Inhibits Asthma, • Monitor ABG’s and theophylline
Aminophylline dilator, rapid phosphodeterase, emphysema, levels. Peak serum concentration
Xanthine digitalization, an enzyme chronic should be taken 1 hour after I.V
Brand Name: give 0.4 to 0.6 responsible for obstructive 1-2 hrs. following immediate
Theophylline mg I.V. breaking down pulmonary release dose, 3-8 hours following
ethylenediamine initially, cyclic AMP, disease (COPD), extended release.
followed by resulting in or chronic airway • Take through level just before
0.1 to 0.3 mg bronchodilation and limitations (CAL) next dose or 2 hrs. after meals.
I.V. every 4 reducing airway • Monitor vital signs, respirations
hours, resistance and breath sounds.
 Name of Classific Dosage/ Route MOA Indication Nursing Responsibility
Drug ation Frequency

Generic Name: Anti- 10-50 mg IV IV or IM Blocks • Upper • Instruct client to take with
Diphenhydrami histamin or deep IM up histamine Respiratory food; drink a minimum of 8
ne Chloride e to 100 mg not release at allergic glasses of fluid/day.
to exceed 400 H1 blockers disorder • Monitor Vital Signs, Intake
Brand Name: mg/24hr. • Anaphylacti and output. If secretions are
Benadryl c reaction thick, use a humidifier.

Name of Classificati Dosage/ Route MOA Indication Nursing

Drug on Frequency Responsibility

Generic Name: Calcium 30-60 mg P.O Blocks calcium • Hypertension • Monitor ECG and
Nifedipine Channel OD access to the cells • Vasopastic avoid giving when
Hydrochloride Blockers causing decrease in angina heart blocks are
contractility decrease • Classic hronic present.
Brand Name: anterior constriction stable angina • Protect the drug
Procardia decrease PVR from light and
• Atrial fibrillation
decrease BP. moisture.
of flutter
• Migraine • Instruct to increase
headaches dietary fiber, fluid
intake, and exercise.
 Name of Classific Dosage/ Route MOA Indication Nursing Responsibility
Drug ation Frequency

Generic Name: Central Tablet: >100 PO Decreases the Hypertension • Check the BP first before
Clonidine Alpha2 mcg b.i.d then release of giving this drug.
hydrochloride Agonists increase in adrenergic • If rate is > 20 bpm over
100-200 hormones from normal, notify provider
Brand Name: mcg/day until brain, resulting • Take with meals; for
Catapres desired in a decrease in nausea eat unsalted
response is the peripheral crackers or dry toast.
desired vascular
resistance and
blood pressure • Lie down if dizzy

Name of Classificati Dosage/ Route MOA Indication Nursing

Drug on Frequency Responsibility

Generic Name: Beta2 Cardiac IV, SQ, IM Stimulates beta • Asthma • If blood pressure
Epinephrine Adrenergic arrest: 1 mg receptors in lung. Bronchitis increases
Agonists IV of q 3-5 • Emphysema sharply, rapid-
Brand Name: min; Relaxes bronchial • All cardiac acting
Adrenalin Anaphylaxis: smooth muscle. arrest, vasodilators such
0.1- 1 mg SQ anaphylaxis as nitrates or
or IM Increases vital alpha blockers
Asthma: 0.1- capacity
• Symptomatic
bradycardia. can be given to
0.3 mg SQ or  BP,  HR,  PR counteract
IM • Relief of
Refractory Decreases airway bronchospasm
occurring • Monitor V/S. and
bradycardia resistance.
during check for cardiac
and
anesthesia dysrhythmias
hypotension:
2-10ug/min • bronchospasm
 Name of Classific Dosage/ Route MOA Indication Nursing
Drug ation Frequency Responsibility

Generic Name: Cortico- 100-500 mg: then IM, IV Synthesize by • Anti-inflammatory • Monitor V/S, BP,
Hydrocortison steroids nay be repeated adrenal cortex. • Immunosuppressa weight, , electrolytes,
e sodium at 2-, 4-, and 6 hr. Exhibits anti- nt EKG, and TB skin
succinate intervals inflammatory • Replacement in test results,
depending on the properties. adrenal cortical • administer oral drugs
Brand Name: response and Suppresses normal sufficiency with food or milk
Solu-cortef severity of immune response. early in the morning
conditions Increase • Withdraw medication
carbohydrate, fats
slowly.
and protein
metabolism

Name of Classifi Dosage/ Route MOA Indication Nursing Responsibility

Drug cation Frequency

Generic Name: Antico- Initial loading IV Combines • Thrombosis. • Monitor for signs of unsual
Heparin agulant dose:10, 000-20,000 with • Reduces the bleeding (hematuria, GI
Sodium units antithrombin risk of bleeding, gum bleeding).
Maintenance:8,000- III to retard myocardial • Monitor IV site carefully.
Brand Name: 10,000 units q 8 hr or thrombin infarction • Heparin has short half-life,
Heparin 15,000-20,000 units activity (MI), CVA, therefore with
q 12 hr. Use clots discontinuation.
concentrated associated
solution with atrial
fibrillation
• Peripheral
embolism
 Name of Classification Dosage/ Route MOA Indication Nursing
Drug Frequency Responsibility

Generic Name: Electrolyte, 4g in 250 IV, IM Reduces striated • Control of • Monitor serum
Magnesim Anticonvulsant ml by IV muscle contractions convulsions in levels.
Sulfate or 4-5 due to the pre-eclampsia • Monitor knee jerk
deep IM depressant effect on or eclampsia. reflex before
the CNS. Blocks • Severe asthma repeated parenteral
neuromuscular • VF refractory administration
transmission to lidocaine • Maintain urine output
 BP, PR,and at a level of 100 ml q
 RR. 4hrs. during
parenteral
administration
• Antidote is Calcium
Gluconate

Name of Classific Dosage/ Route MOA Indication Nursing

Drug ation Frequency Responsibility

Generic Name: Loop 0.5-1 mg/kg IV Inhibit sodium, • Edema • D iet- K+ for all
Furosemide Diuretics slow IVP over chloride, and water associated with except aldactone
1-2 min, may reabsorption in the CHF • I ntake and Output,
Brand Name: repeat once proximal portion of • Cirrhosis with daily weight
Lasix at 2 mg/kg the ascending loop of ascites or renal
slow IVP over Henle. • U ndesirable effects;
dysfunction
1-2 mins. Fluid and electrolyte
• For imbalance
hypertension
• R eview HR, BP and
or in
electrolytes
combination
with other • E lderly-Careful
antihypertensiv • T ake with or after
e medications. meals and in AM
• ICP, nephritic • I ncrease risk of
syndrome, orthosthatic
hepatic hypotension; move
cirrhosis slowly
• C ancel alcohol
 Name of Classification Dosage/ Route MOA Indication Nursing
Drug Frequency Responsibility

Generic Name: Coronary Acute attack: SL Increases osmotic Oliguria • Monitor V/S.
Isosorbide Vasodilator, 2.5-5 mg q 2- pressure of ,Edema, • Watch for rapid  in
Dinitrate Osmotic 3 hr as glomerular filtrate; Increased BP and symptoms of
Diuretics, required. The thus preventing Intracranial sympathetic
Brand Name: Antanginal dose can be reabsorption of water. Pressure, Treat overactivity
Isordil titrated Increases excretion certain drug
• (ex.  HR, tremor
upward until of sodium and toxicities
anginal is chloride. and agitation)
relieved or • IV solutions may
side effects crystallize
occur. • Redissolve before
infusing by warming
bottle. Never give
solutions with
undissolve crystals.

Name of Classification Dosage/ Route MOA Indication Nursing

Drug Frequency Responsibility

Generic Name: H2 Adults:150 PO Reduces gastric acid • Hypersecretion • Monitor GI

Ranitidine Histamine mg b.i.d secretions. Prevent of stomach discomfort
hydrochloride Antagonists histamine induced acid acids • Periodic evaluation
release by competing • Gastroesophan of blood count
Brand Name: with histamine for H2, geal refux • Gastric Acid
Zantac receptors in the stomach • Long term Secretion Test
prophylaxis of • Renal and hepatic
duodenal function tests
ulcers
• Prevention of • Be alert that the
upper GI bleed elderly need a
in critically ill decrease in the
clients. drug dosage
 Name of Classification Dosage/ Route MOA Indication Nursing Responsibility
Drug Frequency

Generic Name: Bronchodilat 1.25- 5 mg Stimulates beta • Reversible • Monitor breath sounds
Albuterol or, Beta2 nebulized in receptors in lung. airway • Sensorium levels for
Adrenergic 3 ml saline Relaxes bronchial restriction due confusion and
Brand Name: Agonists Asthma: 0.1- smooth muscle. to acute restlessness due to
Ventolin 0.3 mg SQ or Increases vital bronchospasm hypoxia
IM of capacity • Asthma • Monitor V/S.
1:10,000 Decreases airway • Chronic • Check for cardiac
solution resistance. Obstructive dysrhythmias
Pulmonary
Disease

Name of Classific Dosage/ Route MOA Indication Nursing

Drug ation Frequency Responsibility

Generic Name: Alkalizing 1 mEq/kg IVP, IV Neutralizes gastric • Hyperacidity • Monitor urinary pH,
Sodium Agent, may repeat acid. Decrease • Peptic ulcer calcium, electrolytes
Bicarbonate Buffer, 0.5 mEq/kg pepsin activity Hyperkalemia and phosphate
Antacid, 10 min. • Tricyclic levels.
electrolyte. antidepressant • Record amount and
OD consistency of
• Shock stools.
associated with • Clients on low-
severe sodium diets should
diarrhea, evaluate sodium
dehydration, contents of antacids.
uncontrolled
DM
• Reflux
esophagitis
 Name of Classification Dosage/ Route MOA Indication Nursing
Drug Frequency Responsibility

Generic Name: Antianginal, 0.3-0.4 SL Relaxes the vascular • Angina Oral: Instruct to take an
Nitroglycerin Nitrate, mg SL q 5 smooth system pectoris empty stomach with a full
Vasodilator, min, max Myocardial oxygen  CHF glass of water. Do not
Brand Name: Coronary 3 doses consumption associated with chew tablet.
Nitrostat  left ventricular AMI Sublingual: Instruct to
workload  Cardiac load take at first sign of
 arterial BP reducing agent anginal pain.May be
 venous return • Hypertensive repeated q 5 minutes to
max. of 3 doses.
Crisis
Transderm nitro Patch
Instruct to apply OD,
usually in Arm.
Rotation of sites are
necessary

Name of Classification Dosage/ Route MOA Indication Nursing

Drug Frequency Responsibility

Generic Name: Vitamin B Adults: 50- IV, IM A coenzyme Pyridoxine • Monitor for
Pyridoxine Complex 200 mg/day necessary for many deficiency improvement of
Hydrochloride for 3 weeks metabolic functions nervous system
followed by affecting abnormalities
Brand Name: 25-100 carbohydrate, lipid, (anxiety, depression,
Vitamin B6 mg/day as and protein utilization insomia, peripheral
needed. in the body. numbness, and
tremors) and skin
lesions (may cause
anemia/pheriperal
neuritis)
 Name of Classification Dosage/ Route MOA Indication Nursing
Drug Frequency Responsibility

Generic Name: Anticonvulsant Adults: Loading PO, IV Reduces • Grand mal • Provide safety
Phenytoin dose: 10-15 motor cortex • Complex partial during and after a
mg/kg at a rate activity by seizures. seizure.
Brand Name: not to exceed altering • Prevention and • If given in a
Dilantin 50 mg/min; transport of treatment of suspension, shake
then, 100 mg ions. seizures well before pouring.
PO or IV q 6-8 occurring during • If given (IV), it
hr. or following should administered
Pediatric neurosurgery slowly due to
loading dose: potential
15-20 mg/kg in hypotension and
divided dose of dysrhythmias.
5-10 mg/kg
• Administer only
given at a rate
through a saline line
of 1-3
mg/kg/min. • Do not mix with
other drugs.

Name of Classification Dosage/ Route MOA Indication Nursing Responsibility

Drug Frequency
Generic Name: Anticholinergics Bradycardia: IV Blocks • As an anti-sialagogue • Monitor VS.
Atrophine 0.5 -1 mg IV cholinergi for preanesthetic • Report  HR
Sulfate (may give via c receptor medication to prevent • Monitor for
ETT at double sites so or reduce secretions constipation,
Brand Name: dose) q 3-5 response of the respiratory tract oliguria.
Isopto Atropine min, max 0.04 to  To restore cardiac rate
mg/kg acetylcholi • Instruct to take
and arterial pressure 30 mins before
Cardiac ne is during anesthesia.
arrest: 1 mg decreased meals
 To lessen the degree • Eat foods high
q 3-5 min, . of atrioventricular (A-
max 0.04 in fiber and drink
V) heart block when
mg/kg plenty fluids.
increased vagal
 To overcome severe
carotid sinus reflex