Ebook ICU care of abdominal organ transplant patients: Part 2
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Ebook ICU care of abdominal organ transplant patients: Part 2
This page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2who are being considered for transplant or who have recently undergone abdominal organ transplantation present unique challenges in providing care. However, the common preventative strategies in the intensive care unit remain equally important. This chapter addresses general principles of management Ebook ICU care of abdominal organ transplant patients: Part 2 of critically ill patients and highlights important additional considerations in transplant patients. We will focus on:2Preventative strategies againEbook ICU care of abdominal organ transplant patients: Part 2
st venous thromboembolism3Preventative strategies against stress ulcer prophylaxis4Paired sedation weaning and spontaneous breathing trialsElevation oThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2nits (ICUs). In a recent cohort study examining nosocomial infections in ICUs, pneumonia was the underlying cause in more than two-thirds of cases. Patients who develop an episode of nosocomial pneumonia experience an increased length of hospital stay by an average of 7 to 9 days and increased resou Ebook ICU care of abdominal organ transplant patients: Part 2rce consumption and costs per hospitalization. The mortality rate among patients who develop nosocomial pneumonia is estimated to be 20% to 50% higherEbook ICU care of abdominal organ transplant patients: Part 2
than in patients who do not develop nosocomial pneumonia.A particular concern in the ICU is ventilator-associated pneumonia (VAP), defined as pneumonThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2ty and approximately 20% to 30% of patients will die during their hospital course. It is unclear whether high mortality results from the pneumonia itself or because VAP occurs in patients who are sick and have multiple-organ dysfunction. The attributable mortality of VAP has been debated extensively Ebook ICU care of abdominal organ transplant patients: Part 2, and two recent studies examining large databases of ICU patients have estimatedan attributable mortality of 7% to 10%. The increased prevalence of rEbook ICU care of abdominal organ transplant patients: Part 2
esistant organisms in VAP, such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus auereus, and the associated difficulty in treating This page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2their incidence.Risk factors for Health Care-Associated PneumoniaTable 10.1 describes risk factors for HCAP in critically ill patients. The most significant risk factor in the ICU is mechanical ventilation. Although the risk of HCAP in patients with liver disease or transplantation has not been stud Ebook ICU care of abdominal organ transplant patients: Part 2ied extensively, these patients are likely to be at an increased risk for several reasons.First, patients who undergo transplant often require mechaniEbook ICU care of abdominal organ transplant patients: Part 2
cal ventilation prior to transplant because of infection, encephalopathy, or gastrointestinal (Gl) bleeding, and in the immediate post-operative perioThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2ll-mediated immunity. Intubation leaves patients unable to utilize their innate defenses against developing pneumonia, including the cough reflex and the mucociliary clearance of lower respiratory secretions.Third, altered mental status caused by hepatic encephalopathy may also increase risk of aspi Ebook ICU care of abdominal organ transplant patients: Part 2ration and subsequently of pneumonia, akin to higher risk of pneumonia reported in prior studies in patients with neurological conditions (odds ratioEbook ICU care of abdominal organ transplant patients: Part 2
[OR] = 3.4).Fourth, repeated episodes of intubation for procedures, such as upper Gl hemorrhage. may injure the respiratory tract and increase susceptThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2ch as respiratory disease (OR - 2.8) and cardiac disease (OR = 2.3).Preventative StrategiesPrevention of nosocomial pneumonia and VAP is essential in newly transplanted patients, as infections in newly transplanted patients are a significant cause of increased morbidity and mortality. Overall infect Ebook ICU care of abdominal organ transplant patients: Part 2ion rates as high as 33% to 66% following liver transplant have been reported, and in the first month, bacterial infections tend to predominate. CommoEbook ICU care of abdominal organ transplant patients: Part 2
n sites of infection are surgicalTable 10.1 Risk Factors for Nosocomial PneumoniaMechanical ventilationPre-existing heart diseaseCentral nervous systeThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2ve bacteria, including Pseudomonas aueruginosa. Low pre-operative albumin, need for hemodialysis, and prolonged ICU stays increase this risk of infection in orthotopic liver transplant recipients.Several preventative strategies have been examined to reduce the risk of HCAP, including oropharyngeal d Ebook ICU care of abdominal organ transplant patients: Part 2econtamination, probiotics, silver-coated endotracheal tubes, closed-circuit suction tubes, and patient positioning. Of these strategies, elevation ofEbook ICU care of abdominal organ transplant patients: Part 2
the head end of the patient bed in mechanically ventilated patients has been studied most extensively. Elevation of the head of the bed is easy to imThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2 be placed in the semi-recumbent position with the head of the bed elevated at an inclination of 30 to 45 degrees. Several randomized controlled trials have demonstrated that maintaining patients in the semi-recumbent position decreases the incidence of VAP. In a randomized controlled trial by Draku Ebook ICU care of abdominal organ transplant patients: Part 2lovic et al. the incidence of VAP was 34% among patients maintained in a supine position and 8% (p = 0.003) in those maintained in the semi-recumbentEbook ICU care of abdominal organ transplant patients: Part 2
position. Similarly, confirmed cases of VAP were 23% and 5%, respectively (p = 0.018).A study reported that compared to supine position, elevated headThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2as not consistently maintained. Trends toward improved survival and decreased hospital stay, which did not approach statistical significance, were also noted in this meta-analysis. This protective effect is believed to result from decreased aspiration of gastric contents and ensuing colonization of Ebook ICU care of abdominal organ transplant patients: Part 2the respiratory tract with the head of the bed elevated compared to in the supine position.Despite these benefits, elevating the head of the bed is stEbook ICU care of abdominal organ transplant patients: Part 2
ill not consistently achieved, in part because of constraints with other aspects of patient and nursing care. Potential strategies to improve complianThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients w Ebook ICU care of abdominal organ transplant patients: Part 2nursing staff and respiratory therapists to work collaboratively and to emphasize the importance of this simple maneuver may improve compliance. Routine audits to assess compliance with the intervention in a prominent place in the ICUs to encourage change and motivate staff may also be considered.Pr Ebook ICU care of abdominal organ transplant patients: Part 2one positioning has also been evaluated as a potential measure to decrease incidence of VAP. Although prone positioning does improve oxygenation in paEbook ICU care of abdominal organ transplant patients: Part 2
tients with acute lung injury, it does not change the risk of developing nosocomial pneumonia nor does it decrease associated mortality.This page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients wThis page intentionally left blankChapter 10General Management of Patients in Intensive Care UnitFaraaz Shah and Sachin YendeCritically ill patients wGọi ngay
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