Intensive care, admission

GBS may progress up to 4 weeks with a nadir being reached within 2-3 weeks in a majority of patients. Recovery usually begins within 2-A weeks of this nadir, but can be delayed for several months. About one-half of patients become chair- or bed-bound, one-third require intensive care admission, and one-quarter mechanical ventilation (Winer et al., 1988 Rees et al., 1998 Hughes and Comblath, 2005). Functional recovery is a rule and occurs in a majority of patients over 6-12 months however 20-30% of patients are left with significant disability and about 10% require assistance with walking. The mortality rate ranges between 3 and 8%, and most deaths are attributed to cardiac arrest due to autonomic disturbance, respiratory failure or infection, or pulmonary embolism. 

W5. Wade, C. E., Lindberg, J. S Cockrell, J. L Lamiell, J. M Hunt, M. M., Ducey, J., and Jumey, T. H., Upon-admission adrenal steroidogenesis is adapted to the degree of illness in intensive care unit patients. J. Clin. Endocrinol. Metab. 67,223-227 (1988). 

Hospitalization should occur or be considered depending on each patient s symptoms and physical findings. Admission to an intensive care unit may... 

A 66-year-old man is admitted to the intensive care unit of a hospital for treatment of community-acquired pneumonia. He receives ceftriaxone and azithromycin upon admission, rapidly improves, and is transferred to a semiprivate ward room. On day 7 of his hospitalization, he develops copious diarrhea with eight bowel movements that day but is other wise clinically stable. Clostridium difficile-associated colitis is suspected and a toxin assay is sent to confirm this diagnosis. What is an acceptable treatment for the patient s diarrhea The patient is transferred to a single-bed room the following day. The housekeeping staff asks if the old room should be cleaned with alcohol or bleach. Which product should be chosen Why ... 

Acute pancreatitis is usually a self-limiting disease, which regresses spontaneously without further complications. However, in about 20% of cases it leads to organ failure and/or local complications and is associated with high morbidity and mortality rates (B15). Therefore, numerous attempts have been made to predict early the severe course of acute pancreatitis and to assess the possibility of complications. Objective identification of the risk of complications or death is essential for selection of those patients who should be hospitalized in the intensive care unit (ICU) and be subjected to more expensive and aggressive investigations. Moreover, it also permits interinstitutional comparison of data stratified for severity at admission and at the time of therapy. 

Over the next several years, she had recurrent episodes of reactive airway disease. At the age of 4 years, she had a life-threatening episode of acute chest syndrome requiring admission to the intensive care unit and exchange transfusion. She was subsequently transfused with red blood cells monthly for 6 months to prevent recurrence. Two years later, she was again admitted to the intensive care unit with acute chest syndrome. During this admission, she was found to have Streptococcus pneumoniae sepsis and pneumonia. She again received RBC transfusions monthly for 6 months. Following this course of transfusion therapy, she was offered therapy with hydroxyurea, but this therapy was never instituted. 

Just before intensive care unit admission this patient has a low blood pressure and a high heart rate. What is the most likely cause of this ... 

On admission to the intensive care unit her laboratory results were as follows ... 

Severe cases of tetanus generally require admission to an intensive care unit for 3-5 weeks. Weight loss is universal in tetanus and these patients require enteral nutrition. Other important measures include close control of fluid balance, chest physiotherapy to prevent pneumonia, prophylaxis of thromboembolism and intensive nursing care to prevent pressure sores. 

However, because a continuous infusion is required, implantable pumps containing a very concentrated solution of baclofen are used to avoid frequent refills. Inadvertent subarachnoid bolus administration of a concentrated solution will produce cranial spread of baclofen within the CSF, resulting in cerebral effects. This is most hkely to occur when a new catheter or pump is implanted or during surgical revision of a catheter or implantable pump in cases of malfunction. A report of coma after implantation of a baclofen pump in five out of nine consecutive children illustrates this (3). The authors suggested that these children should be monitored in the recovery room for 5 hours postoperatively, in order to cover both the peak effect of any baclofen bolus and the additive effects of other perioperative CNS suppressants, such as opioids, benzodiazepines, or sedative antiemetics. In another report of transient coma after perioperative intrathecal bolus administration it was shown that the management of this complication can require admission to an intensive care unit (4). 

The CIN Consensus Working Panel considered that hemofiltration deserves further investigation using end points unaffected by the experimental intervention, but the high cost and need for intensive care unit admission will also limit the utdity of this prophylactic approach. [149]. 

Case Conclusion Because of her reaction to the terbutaline, PC is placed on IV MgS04. Her contractions abate and she continues on the medication for the next 48 hours. At that time, the medication is discontinued and she remains acon-tractile. She is discharged to home, but presents 2 weeks later with stronger contractions. On her second admission, the MgSO is unable to stop her labor and she delivers a 32-week infant weighing 1400 g. She is quite concerned about her infant, but he does well in the neonatal intensive care unit and is discharged home on day of life 23. 

Raymond et al. reported on a rotation study in a surgical intensive care unit with a different twist.Patients were stratified as either having sepsis/peritonitis or pneumonia, and empiric therapy was cycled every 3 months by syndrome. Fourteen hundred fifty-six admissions and 540 infections were treated over a 2-year period. With similar severity of illness during the before and after periods (mean APACHE II = 19), the authors demonstrated a reduction of length of stay from a mean of 62 days to 39 days, a reduction of vancomycin-resistant enterococcal and methicillin-resistant staphylococcal infection from 14 per 100 admissions to 8 per 100 admissions and death due to any cause dropped from 25 in the before period to 18 in the rotation period. Antimicrobial susceptibility and several other key parameters needed to evaluate the effectiveness of this program were not reported. 

Upon admission, the patient was cyanotic, apneic, and hypotensive. Laboratory results indicated significant acidosis. The patient was intubated, ventilation was initiated, and gastric lavage was performed. Intravenous fluid therapy consisting of Ringers solution followed by 5% dextrose, epinephrine, and sodium bicarbonate was initiated and the patient was transferred to intensive care. The patient was maintained via endotracheal respiration and dopamine therapy. The patient became anuric approximately 7.5 hours after admission, and her health continued to deteriorate over the next day she died 28 hours after admission. 

Although infant botulism was not recognized until a large outbreak occurred in Califomia in 1976 (Pickett et ah, 1976), it is currently the most prevalent form of botulism in the United States, accounting for approximately 70% of all cases (Shapiro et al., 1998). Because infant botulism results from a continual production of BoNT, it appears to be more effectively treated by antitoxin than is foodborne botulism. In a recently concluded 5 year randomized clinical trial carried out with a human botulinum immune globulin (BIG-IV), it was found that administration of BIG-IV within 3 days of hospitalization resulted in a 3 week reduction in the mean hospital stay, as well as substantial reductions in the time needed for intensive care and mechanical ventilation (Amon et al., 2006). In a nationwide open label study, BlG-lV was found to be effective even when administered 4—7 days after hospital admission, although to a somewhat lesser extent than when infusion was initiated at 3 days (Arnon et al., 2006). 

The emergency department use of aminophylline, a moderate bron-chodUator, for acute asthma has not been recommended for a number of years. Clinical trials of aminophylline in adults and children hospitalized with acute asthma have not reported sufficient evidence of efficacy (improvement in lung function and reduced hospital stay) but have reported an increased risk of adverse effects. However, two smdies of aminophylline in children with severe disease suggested a possible small benefit in reducing intensive care unit admissions. Adverse effects of theophylline include nausea and vomiting and potentiation of the cardiac effects of the inhaled /32-agonists. 

Patients should be categorized into either prognostically mild or severe disease using any one of a number of validated multiple-factor scoring systems (Table 39 ). " Two widely used measures include Ranson s criteria and the Acute Physiology and Chronic Health Evaluation (APACHE II). The APACHE II (>8 points) system is more sensitive and specific than Ranson s criteria (>3 criteria), but it is also more complex. The APACHE II system uses 14 indicators of physiological and biochemical function that can be readily calculated upon admission to an intensive care unit. Ranson s criteria includes 11 variables that must be monitored at the time of admission and during the initial 48 hours of hospitalization. Patients with fewer than three Ranson criteria have a mortality rate of less than 1%, while... 

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