Background: In the summer of 2010, the intensive care unit (ICU) Clinical Practice Committee at t... more Background: In the summer of 2010, the intensive care unit (ICU) Clinical Practice Committee at the University of Texas MD Anderson Cancer Center was charged with developing and implementing an early mobilization program (EMP) for critically ill cancer patients in the ICU. The driving forces included the perception and observation of primary admitting services and the ICU service of infrequent mobilization of critically ill patients in the ICU. Additionally, early mobilization in critically ill patients was emerging as a potential prevention strategy for several complications associated with critical illness including reduced disability and dependence in survivors. Much of the critical care literature on EMP is focused on patients requiring mechanical ventilation. However, both ventilated and nonventilated critically ill patients equally benefit from early exercise programs (Burtin et al, 2009). In patients requiring mechanical ventilation, EMP have been found to be safe and are ass...
Hafrsfjord og kampen om vikingtidens flåtebaser Innledning Søk etter slagsteder og arkeologiske u... more Hafrsfjord og kampen om vikingtidens flåtebaser Innledning Søk etter slagsteder og arkeologiske undersøkelser av slike lokaliteter har fått økt fokus i de senere år. For eksempel har det lykkes å finne åstedene for slagene på Re i Vestfold som stod mellom grupperinger i den norske borgerkrigsstriden på 1100-tallet (Jacobsen og Bandlien 2013). Av slagsteder i eldre norsk historie er Hafrsfjord i Rogaland det mest kjente ved siden av Stiklestad. Slaget i Hafrsfjord og dets rolle i den norske rikssamlingsprosessen har vaert et viktig forskningsfelt siden 1800-tallet. I denne artikkelen forsøkes en ny tilnaerming for om mulig å kaste lys over hvorfor det antatt avgjørende slaget sannsynligvis skjedde akkurat der. Det gjøres ved å sammenligne slagstedet i Hafrsfjord med andre åsteder for viktige sjøslag i omtrent samme periode, det vil si fra ca. 850 og inn i første halvdel av 900-tallet. Det var vanskelig å påvise slagsteder innen Norge som har noen vesentlige likheter med Hafrsfjord (Opedal og Elvestad 2014a, 2014b). Men det må understrekes at upresis lokalisering av mange sjøslag vanskeliggjør slike studier i Norge. De innledende undersøkelsene antydet derimot en overraskende tydelig topografisk likhet mellom Hafrsfjord og flere slagsteder i Irland og Storbritannia der vikinggrupper var involvert. Internasjonalt sett ser det dermed ut til at slagstedet i Hafrsfjord ikke var noe unikt; tvert imot synes det å vaere helt typisk for sin tid. Denne observasjonen inspirerte til å sammenligne åstedene for sjøslag i vest mer systematisk for å se om det kunne gi nye perspektiver på det som skjedde i Hafrsfjord. Hva slags steder var det som det oppsto konflikt om? Hadde de noen fellestrekk, som for eksempel grunnleggende topografiske likheter? Skriftlige kilder som nevner sjøslag i Irland og England, er blitt gjennomgått for å finne fram til disse stedene og se om de hadde visse felles aspekter. Resultatene av denne studien kan så brukes til å diskutere hvorfor det viktige slaget sto akkurat i Hafrsfjord. Slaget i Hafrsfjord har en helt spesiell plass i norsk historie. Snorre Sturlasons storslåtte framstilling av rikssamlingen når klimaks i Hafrsfjord, der Harald Hårfagre beseirer sine motstandere og blir den første rikskongen. Saerlig i den norske nasjonsbyggingsfasen på 1800-og tidlig 1900-tall fikk Hafrsfjord naermest en mytisk rolle i nasjonens fødsel. I vår tids mer nøkterne historieskriving blir rikssamlingen fortsatt sett på som et vendepunkt i den tidlige fasen i statsbyggingsprosessen i Norge. Rett nok har man stilt spørsmål om hvor stort område Harald egentlig kontrollerte etter slaget. Skaldestrofer indikerer at det direkte herredømmet primaert dreide seg om den sørvestlige delen av Norge. Her lå kongsgårdene Harald Hårfagre enevoldskonge ca. 870 Tormod Torfaeus 875 Gerhard Schøning 885
(p<0.01).Overall, elective surgery hospital mortality decreased from 1.78% in Phase 1 to 1.44%... more (p<0.01).Overall, elective surgery hospital mortality decreased from 1.78% in Phase 1 to 1.44% in Phase 2 (NS). Conclusions: The strategy of safely moving surgical elective patients from ICU to IMCU has been successful. The majority of the elective surgical cases now go directly to IMCU and overall HLOS is lower by transitioning patients to IMCU post operatively instead of ICU. There are positive trends for decreases in transfers from IMCU to ICU and morality rates. Though the Intermediate Care Unit concept is popular, the literature on safety and efficient remains mixed. We attribute our improvement to careful planning, good case selection and monitoring.
9611 Background: Dyspnea is one of the most common and distressing symptoms in cancer patients. F... more 9611 Background: Dyspnea is one of the most common and distressing symptoms in cancer patients. Few treatments are evidence based because research in this area is difficult. The role of HFO and BiPAP in the palliation of severe refractory dyspnea has not been well characterized.We examined the changes in dyspnea, physiologic parameters and adverse effects in patients receiving HFO and BiPAP. Methods: In this phase II “pick the winner” randomized trial, we assigned hospitalized advanced cancer patients with refractory dyspnea to either HFO or BiPAP for 2 hours. We assessed dyspnea with the numeric rating scale (NRS) and modified Borg scale (MBS) before and after intervention. We also documented the vital signs, transcutaneous carbon dioxide and adverse effects. We used the sign rank test to compare before and after each intervention, and the Wilcoxon rank sum test to compare between arms with intention-to-treat analysis. Results: Thirty patients were enrolled (1:1 ratio) and 23 (77%)...
The objective was to describe the characteristics and outcomes of critically ill cancer patients ... more The objective was to describe the characteristics and outcomes of critically ill cancer patients who received noninvasive positive pressure ventilation (NIPPV) vs invasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure. A retrospective cohort study of consecutive adult intensive care unit (ICU) cancer patients who received either conventional invasive mechanical ventilation or NIPPV as first-line therapy for hypoxemic respiratory failure. Of the 1614 patients included, the NIPPV failure group had the greatest hospital length of stay, ICU length of stay, ICU mortality (71.3%), and hospital mortality (79.5%) as compared with the other 2 groups (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). The variables independently associated with NIPPV failure included younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99; P=.031), non-Caucasian race (OR, 1.61; 95% CI, 1.14-2.26; P=.006), presence of a hematologic malignancy (OR, 1.87; 95% CI, 1.33-2.64; P=.0003), and a higher Sequential Organ Failure Assessment score (OR, 1.12; 95% CI, 1.08-1.17; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). There was no difference in mortality when comparing early vs late intubation (less than or greater than 24 or 48 hours) for the NIPPV failure group. Noninvasive positive pressure ventilation failure is an independent risk factor for ICU mortality, but NIPPV patients who avoided intubation had the best outcomes compared with the other groups. Early vs late intubation did not have a significant impact on outcomes.
Background and objective: It is unclear if physiologic measures are useful for assessing dyspnea.... more Background and objective: It is unclear if physiologic measures are useful for assessing dyspnea. We examined the association among the subjective rating of dyspnea according to patients with advanced cancer, caregivers and nurses, and various physiologic measures. Methods: We conducted a cross-sectional survey of patients with cancer hospitalized at MD Anderson Cancer Center. We asked patients, caregivers, and nurses to assess the patients' dyspnea at the time of study enrollment independently using a numeric rating scale (0 = none, 10 = worst). Edmonton Symptom Assessment Scale (ESAS) ratings, causes of dyspnea, vitals, and Respiratory Distress Observation Scale [RDOS] ratings were collected. Results: A total of 299 patients were enrolled in the study: average age 62 (range 20-98), female 47%, lung cancer 37%, and oxygen use 57%. The median RDOS rating was 2/16 (interquartile range 1-3) and the number of potential causes was 3 (range 2-4), with pleural effusion (n = 166, 56%), pneumonia (n = 144, 48%), and lung metastasis (n = 125, 42%) being the most common. The median intensity of patients' dyspnea at the time of assessment was 3 (interquartile range 0-6) for patients, 4 (interquartile range 1-6) for caregivers, and 2 (interquartile range 0-3) for bedside nurses. Patients' expression of dyspnea correlated moderately with caregivers' (r = 0.68, p < 0.001) and nurses' (r = 0.50, p < 0.001) assessments, and weakly with RDOS (r = 0.35, p < 0.001), oxygen level (r = 0.32, p < 0.001), and the number of potential causes (r = 0.19, p = 0.001). In multivariate analysis, patients' dyspnea was only independently associated with ESAS dyspnea ( p = 0.002) and dyspnea as assessed by caregivers ( p < 0.001). Conclusion: Patients' level of dyspnea was weakly associated with physiologic measures. Caregivers' perception may be a useful surrogate for dyspnea assessment.
Background: In the summer of 2010, the intensive care unit (ICU) Clinical Practice Committee at t... more Background: In the summer of 2010, the intensive care unit (ICU) Clinical Practice Committee at the University of Texas MD Anderson Cancer Center was charged with developing and implementing an early mobilization program (EMP) for critically ill cancer ...
Context-Dyspnea is one of the most distressing symptoms for cancer patients. The role of high flo... more Context-Dyspnea is one of the most distressing symptoms for cancer patients. The role of high flow oxygen (HFO) and bilevel positive airway pressure (BiPAP) in the palliation of dyspnea has not been well characterized. Objectives-To determine the feasibility of conducting a randomized trial of HFO and BiPAP in cancer patients, and to examine the changes in dyspnea, physiologic parameters and adverse effects with these modalities. Methods-In this randomized study (ClinicalTrials.gov Identifier: NCT01518140), we assigned hospitalized patients with advanced cancer and persistent dyspnea to either HFO or BiPAP for two hours. We assessed dyspnea with a numeric rating scale (NRS) and modified Borg scale (MBS) before and after the intervention. We also documented vital signs, transcutaneous carbon dioxide and adverse effects. Results-Thirty patients were enrolled (1:1 ratio) and 23 (77%) completed the assigned intervention. HFO was associated with improvements in both NRS (mean 1.9, 95% confidence interval [CI] 0.4, 3.4; P=0.02) and MBS (mean 2.1, 95% CI 0.6, 3.5; P=0.007). BiPAP also was associated with improvements in NRS (mean 3.2; 95% CI 1.3, 5.1; P=0.004) and MBS (mean 1.5, 95% CI −0.3, 3.2; P=0.13). There were no significant differences between HFO and BiPAP in dyspnea NRS (P=0.14) and MBS (P=0.47). Oxygen saturation improved with HFO (93% vs. 99%, P=0.003), and respiratory rate had a non-statistically significant decrease with both interventions (HFO-3; P=0.11; BiPAP-2, P=0.11). No significant adverse effects were observed. Conclusion-HFO and BiPAP alleviated dyspnea, improved physiologic parameters and were safe. Our results justify larger randomized controlled trials to confirm these findings.
Background: In the summer of 2010, the intensive care unit (ICU) Clinical Practice Committee at t... more Background: In the summer of 2010, the intensive care unit (ICU) Clinical Practice Committee at the University of Texas MD Anderson Cancer Center was charged with developing and implementing an early mobilization program (EMP) for critically ill cancer patients in the ICU. The driving forces included the perception and observation of primary admitting services and the ICU service of infrequent mobilization of critically ill patients in the ICU. Additionally, early mobilization in critically ill patients was emerging as a potential prevention strategy for several complications associated with critical illness including reduced disability and dependence in survivors. Much of the critical care literature on EMP is focused on patients requiring mechanical ventilation. However, both ventilated and nonventilated critically ill patients equally benefit from early exercise programs (Burtin et al, 2009). In patients requiring mechanical ventilation, EMP have been found to be safe and are ass...
Hafrsfjord og kampen om vikingtidens flåtebaser Innledning Søk etter slagsteder og arkeologiske u... more Hafrsfjord og kampen om vikingtidens flåtebaser Innledning Søk etter slagsteder og arkeologiske undersøkelser av slike lokaliteter har fått økt fokus i de senere år. For eksempel har det lykkes å finne åstedene for slagene på Re i Vestfold som stod mellom grupperinger i den norske borgerkrigsstriden på 1100-tallet (Jacobsen og Bandlien 2013). Av slagsteder i eldre norsk historie er Hafrsfjord i Rogaland det mest kjente ved siden av Stiklestad. Slaget i Hafrsfjord og dets rolle i den norske rikssamlingsprosessen har vaert et viktig forskningsfelt siden 1800-tallet. I denne artikkelen forsøkes en ny tilnaerming for om mulig å kaste lys over hvorfor det antatt avgjørende slaget sannsynligvis skjedde akkurat der. Det gjøres ved å sammenligne slagstedet i Hafrsfjord med andre åsteder for viktige sjøslag i omtrent samme periode, det vil si fra ca. 850 og inn i første halvdel av 900-tallet. Det var vanskelig å påvise slagsteder innen Norge som har noen vesentlige likheter med Hafrsfjord (Opedal og Elvestad 2014a, 2014b). Men det må understrekes at upresis lokalisering av mange sjøslag vanskeliggjør slike studier i Norge. De innledende undersøkelsene antydet derimot en overraskende tydelig topografisk likhet mellom Hafrsfjord og flere slagsteder i Irland og Storbritannia der vikinggrupper var involvert. Internasjonalt sett ser det dermed ut til at slagstedet i Hafrsfjord ikke var noe unikt; tvert imot synes det å vaere helt typisk for sin tid. Denne observasjonen inspirerte til å sammenligne åstedene for sjøslag i vest mer systematisk for å se om det kunne gi nye perspektiver på det som skjedde i Hafrsfjord. Hva slags steder var det som det oppsto konflikt om? Hadde de noen fellestrekk, som for eksempel grunnleggende topografiske likheter? Skriftlige kilder som nevner sjøslag i Irland og England, er blitt gjennomgått for å finne fram til disse stedene og se om de hadde visse felles aspekter. Resultatene av denne studien kan så brukes til å diskutere hvorfor det viktige slaget sto akkurat i Hafrsfjord. Slaget i Hafrsfjord har en helt spesiell plass i norsk historie. Snorre Sturlasons storslåtte framstilling av rikssamlingen når klimaks i Hafrsfjord, der Harald Hårfagre beseirer sine motstandere og blir den første rikskongen. Saerlig i den norske nasjonsbyggingsfasen på 1800-og tidlig 1900-tall fikk Hafrsfjord naermest en mytisk rolle i nasjonens fødsel. I vår tids mer nøkterne historieskriving blir rikssamlingen fortsatt sett på som et vendepunkt i den tidlige fasen i statsbyggingsprosessen i Norge. Rett nok har man stilt spørsmål om hvor stort område Harald egentlig kontrollerte etter slaget. Skaldestrofer indikerer at det direkte herredømmet primaert dreide seg om den sørvestlige delen av Norge. Her lå kongsgårdene Harald Hårfagre enevoldskonge ca. 870 Tormod Torfaeus 875 Gerhard Schøning 885
(p<0.01).Overall, elective surgery hospital mortality decreased from 1.78% in Phase 1 to 1.44%... more (p<0.01).Overall, elective surgery hospital mortality decreased from 1.78% in Phase 1 to 1.44% in Phase 2 (NS). Conclusions: The strategy of safely moving surgical elective patients from ICU to IMCU has been successful. The majority of the elective surgical cases now go directly to IMCU and overall HLOS is lower by transitioning patients to IMCU post operatively instead of ICU. There are positive trends for decreases in transfers from IMCU to ICU and morality rates. Though the Intermediate Care Unit concept is popular, the literature on safety and efficient remains mixed. We attribute our improvement to careful planning, good case selection and monitoring.
9611 Background: Dyspnea is one of the most common and distressing symptoms in cancer patients. F... more 9611 Background: Dyspnea is one of the most common and distressing symptoms in cancer patients. Few treatments are evidence based because research in this area is difficult. The role of HFO and BiPAP in the palliation of severe refractory dyspnea has not been well characterized.We examined the changes in dyspnea, physiologic parameters and adverse effects in patients receiving HFO and BiPAP. Methods: In this phase II “pick the winner” randomized trial, we assigned hospitalized advanced cancer patients with refractory dyspnea to either HFO or BiPAP for 2 hours. We assessed dyspnea with the numeric rating scale (NRS) and modified Borg scale (MBS) before and after intervention. We also documented the vital signs, transcutaneous carbon dioxide and adverse effects. We used the sign rank test to compare before and after each intervention, and the Wilcoxon rank sum test to compare between arms with intention-to-treat analysis. Results: Thirty patients were enrolled (1:1 ratio) and 23 (77%)...
The objective was to describe the characteristics and outcomes of critically ill cancer patients ... more The objective was to describe the characteristics and outcomes of critically ill cancer patients who received noninvasive positive pressure ventilation (NIPPV) vs invasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure. A retrospective cohort study of consecutive adult intensive care unit (ICU) cancer patients who received either conventional invasive mechanical ventilation or NIPPV as first-line therapy for hypoxemic respiratory failure. Of the 1614 patients included, the NIPPV failure group had the greatest hospital length of stay, ICU length of stay, ICU mortality (71.3%), and hospital mortality (79.5%) as compared with the other 2 groups (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). The variables independently associated with NIPPV failure included younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99; P=.031), non-Caucasian race (OR, 1.61; 95% CI, 1.14-2.26; P=.006), presence of a hematologic malignancy (OR, 1.87; 95% CI, 1.33-2.64; P=.0003), and a higher Sequential Organ Failure Assessment score (OR, 1.12; 95% CI, 1.08-1.17; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001). There was no difference in mortality when comparing early vs late intubation (less than or greater than 24 or 48 hours) for the NIPPV failure group. Noninvasive positive pressure ventilation failure is an independent risk factor for ICU mortality, but NIPPV patients who avoided intubation had the best outcomes compared with the other groups. Early vs late intubation did not have a significant impact on outcomes.
Background and objective: It is unclear if physiologic measures are useful for assessing dyspnea.... more Background and objective: It is unclear if physiologic measures are useful for assessing dyspnea. We examined the association among the subjective rating of dyspnea according to patients with advanced cancer, caregivers and nurses, and various physiologic measures. Methods: We conducted a cross-sectional survey of patients with cancer hospitalized at MD Anderson Cancer Center. We asked patients, caregivers, and nurses to assess the patients' dyspnea at the time of study enrollment independently using a numeric rating scale (0 = none, 10 = worst). Edmonton Symptom Assessment Scale (ESAS) ratings, causes of dyspnea, vitals, and Respiratory Distress Observation Scale [RDOS] ratings were collected. Results: A total of 299 patients were enrolled in the study: average age 62 (range 20-98), female 47%, lung cancer 37%, and oxygen use 57%. The median RDOS rating was 2/16 (interquartile range 1-3) and the number of potential causes was 3 (range 2-4), with pleural effusion (n = 166, 56%), pneumonia (n = 144, 48%), and lung metastasis (n = 125, 42%) being the most common. The median intensity of patients' dyspnea at the time of assessment was 3 (interquartile range 0-6) for patients, 4 (interquartile range 1-6) for caregivers, and 2 (interquartile range 0-3) for bedside nurses. Patients' expression of dyspnea correlated moderately with caregivers' (r = 0.68, p < 0.001) and nurses' (r = 0.50, p < 0.001) assessments, and weakly with RDOS (r = 0.35, p < 0.001), oxygen level (r = 0.32, p < 0.001), and the number of potential causes (r = 0.19, p = 0.001). In multivariate analysis, patients' dyspnea was only independently associated with ESAS dyspnea ( p = 0.002) and dyspnea as assessed by caregivers ( p < 0.001). Conclusion: Patients' level of dyspnea was weakly associated with physiologic measures. Caregivers' perception may be a useful surrogate for dyspnea assessment.
Background: In the summer of 2010, the intensive care unit (ICU) Clinical Practice Committee at t... more Background: In the summer of 2010, the intensive care unit (ICU) Clinical Practice Committee at the University of Texas MD Anderson Cancer Center was charged with developing and implementing an early mobilization program (EMP) for critically ill cancer ...
Context-Dyspnea is one of the most distressing symptoms for cancer patients. The role of high flo... more Context-Dyspnea is one of the most distressing symptoms for cancer patients. The role of high flow oxygen (HFO) and bilevel positive airway pressure (BiPAP) in the palliation of dyspnea has not been well characterized. Objectives-To determine the feasibility of conducting a randomized trial of HFO and BiPAP in cancer patients, and to examine the changes in dyspnea, physiologic parameters and adverse effects with these modalities. Methods-In this randomized study (ClinicalTrials.gov Identifier: NCT01518140), we assigned hospitalized patients with advanced cancer and persistent dyspnea to either HFO or BiPAP for two hours. We assessed dyspnea with a numeric rating scale (NRS) and modified Borg scale (MBS) before and after the intervention. We also documented vital signs, transcutaneous carbon dioxide and adverse effects. Results-Thirty patients were enrolled (1:1 ratio) and 23 (77%) completed the assigned intervention. HFO was associated with improvements in both NRS (mean 1.9, 95% confidence interval [CI] 0.4, 3.4; P=0.02) and MBS (mean 2.1, 95% CI 0.6, 3.5; P=0.007). BiPAP also was associated with improvements in NRS (mean 3.2; 95% CI 1.3, 5.1; P=0.004) and MBS (mean 1.5, 95% CI −0.3, 3.2; P=0.13). There were no significant differences between HFO and BiPAP in dyspnea NRS (P=0.14) and MBS (P=0.47). Oxygen saturation improved with HFO (93% vs. 99%, P=0.003), and respiratory rate had a non-statistically significant decrease with both interventions (HFO-3; P=0.11; BiPAP-2, P=0.11). No significant adverse effects were observed. Conclusion-HFO and BiPAP alleviated dyspnea, improved physiologic parameters and were safe. Our results justify larger randomized controlled trials to confirm these findings.
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