The power of Word in the ICU. By Mariana Pedace

The Intensive Care Unit is one of the services where the more intense events could be lived in a Hospital.

The state of health of the patients is critical. The family experiences heartbreaking sensations and professionals must take decisions extremely complex under pressure of time and difficulty. Anguish, pain, uncertainty, the voltage is present at the corridors of the ICU and are current for all the actors.

However, the touching surprise of an improvement unexpected, the joy of return to communicate with a person that not was lucid during days and the hope of starting a project of life that seemed lost also are present. Time doesn´t escape to this avalanche of feelings and acquires another rhythm: sometimes runs very fast, others, too slow, or even, in certain circumstances, seems to be arrested.

This tide of feelings and events can be excessive and exhausting for all the protagonists that stay by different reasons in so end and amazing place of the Hospital. 

As professional, what can we do to channel this whirlwind of emotions and experiences?. What tools do we have for cushioning or even, to transform it in something valuable and significant?

The formula is much simple than we can imagine. We have just to appeal to the more powerful and economical resource of all human beings have: the word. The words allow baste mentally the sensations, weaving networks, explain us what happens, insert it in our history and in this way, to capitalize on the impact that generate. We onlyl must make us the question: "who am I?" to notice that we all "are made of stories", as says the great writer Eduardo Galeano. The stories allow to give meaning to our experiences. Human beings need "as the air we breathe" what happens to us makes sense to preserve a relative psychic balance.


To facilitate these stories arise and deploy, the ICU professionals have another also invaluable resource: listening. Approaching, looking to the eyes, letting talk without judging or rejecting feelings of whom is expressing. Giving signals that we are paying attention by gestures as nodding, occasionally summarizing what he says or showing that one understands what they are feeling. The amount of time that can devote to this task is much less important that the quality that we can give people, to consider the effect that has on who speaks and on ourselves to be listening to.

If all the protagonists of the ICU take some minutes to talk and listen what happens to us, the intense experiences we live daily can process subjectively. And in doing so, suffering reduces and the avalanche of unconnected events become episodes that may make sense in the unique history of working in an ICU. It is not about extraordinary resources or have much time. The only thing we need is to be aware of returning what differentiates us as humans: language and communication. They are the privileged via for the betting of work in one of the places more intense of the Hospital can renew day to day.

Mariana Pedace
Psychologist at Hospital Italiano de Buenos Aires

Lessons from Bankstown

A report has been released by the Chief Medical Officer, NSW, outlining the finding of the recent events in Bankstown-Lidcombe Hospital, where a baby died following a neonatal resuscitation. There are lessons to be learned for all of us from this tragic case. Here, we summarise the findings. The full report can be read here.

 

What happened?

In June 2016, a neonate (Baby 1) was resuscitated in the operating theatres. The baby survived, but there was an unexpected poor outcome and so a RCA (Root Cause Analysis investigation) was initiated. A few weeks later, in July 2016, a second baby (Baby 2) was resuscitated in the same operating theatre. The baby tragically died. This case was referred to the coroner and consequently the police became involved.

The day after the death of Baby 2, a paediatrician requested testing of the gas outlets in this operating theatre. It was tested one week later and it was found that the oxygen outlet was emitting nitrous oxide.

 

When were the outlets initially installed?

18 months earlier, the hospital was using oxygen cylinders for neonatal resuscitation. On one occasion, a baby required resuscitation in the birthing suit using the oxygen cylinders, but the oxygen tank ran out. The baby had to be transferred to Special Care where they had more oxygen available. An RCA was instigated in this case, and consequently it was decided to install piped oxygen to the birthing suite and also to the neonatal resuscitation area in theatres.

This was installed in July 2015.

 

How many babies were resuscitated in this theatre?

Although the gas outlet was installed in July 2015, the outlet was not used in this theatre (one of 8 theatres) until June 2016 when Baby 1 was born. After checking records retrospectively, only Baby 1 and Baby 2 were resuscitated with gas in this theatre.

 

How was nitrous oxide connected to the oxygen outlet?

The report indicates two areas where mistakes occurred: the procedure for installing the gas; and the procedure for verifying the gas post-installation.

The gas was installed by an independent company. I am not an engineer, but my understanding of the process is as follows:

  • when installing a new gas outlet, the engineer is required to isolate only the gas required
  • the pipe for this gas is then drained of pressure
  • when the pipe is then cut to make a new connection there will be no pressurised gas in that pipe
  • if there is any pressure detected, then that indicates that the wrong gas is being attached to the new connection

In this case, rather than isolating just the oxygen gas, the engineer isolated all the gases, including nitrous oxide. Therefore, when cutting the pipe, there would be no indication that the wrong pipe had been cut.

Secondly, after installation the gas should have been verified as being oxygen. This verification should have been witnessed by a member of clinical staff who is experienced in delivering medical gases. The engineer has noted twice on the forms that the oxygen was tested and was 100% oxygen. This cannot have been the case as the actual reading would have been 0% oxygen. No clinical staff verified or witnessed this testing.

 

What are the report findings and recommendations?

The report identifies issues with the engineering process and also the governance within the hospital.

The RCA made a recommendation for submission to the Australian Resuscitation Council to review the existing neonatal resus algorithm. It recommends that a section be added about unexpected hypoxia which includes consideration of the gas outlets.

 

This is a tragic case and must be very stressful for all those involved. As clinicians who are frequently involved in neonatal resus, we have a process for reviewing equipment when faced with unexpected hypoxia during neonatal resuscitation. From now on, we should consider gas outlets as part of this trouble-shooting process and this may need to include a final step of disconnecting the baby from the piped gases and trialling on a self-inflating bag in room air.

RINSEA terápiás hipotermia a kezdeti lelkesedés (Holzer 2002)…



RINSE

A terápiás hipotermia a kezdeti lelkesedés (Holzer 2002) óta egyre kevésbé tűnik előnyösnek. Először az derült ki, hogy 36 fok legalább olyan jó, mint a 32 (Nielsen, 2013). Sokan azt gondolták, azért nem sikerült bizonyítani a hipotermia előnyét, mert nem elég korán kezdjük meg a keringésleállást követőn, így a károsodás már megtörténik, mire a hűtést megkezdjük.A friss RINSE vizsgálatban már a CPR alatt megkezdték a hideg infúzióval való hűtést (átlag 647ml), de így is korán abbahagyták a vizsgálatot, mert úgy tűnt a hipotermia rontotta a ROSC esélyét és nem javított a neurológiai kimenetelen sem.

2002 Holzer

http://www.nejm.org/doi/full/10.1056/NEJMoa012689#t=article

2013 TTM

http://www.nejm.org/doi/full/10.1056/NEJMoa1310519#t=article

2016 RINSE

http://circ.ahajournals.org/content/early/2016/08/25/CIRCULATIONAHA.116.021989

How deep should I place my CVC?

CVC
All the hard parts are done in the placement of your central line. You nicked the vein and NOT the artery. The wire threaded smoothly. You got confirmation on your ultrasound. Now, you just insert the triple lumen in over the wire. Inserting a central line to the right depth on your first try without needing to adjust after your post-line confirmation chest x-ray takes some practice.
The goal is to get the tip of your catheter in the SVC above the level of the pericardial reflection. You should aim to get the catheter tip lying in the long axis of the SVC without any abutment of the vein. Too deep, and you risk erosion or perforation of surrounding vasculature. You even run the risk of arrhythmia if you go really deep into the heart chambers. Not deep enough, and your line may not effectively deliver meds, and it runs a higher risk of thrombus formation and infection.
anatomy
The schematic below shows the potential zones for catheter tip positioning. Zone A represents the optimal area for left-sided central lines. At this level, the central line is more likely to lie parallel to the vessel walls. Zone B represents an optimal location for right-sided central lines. Since it’s a straighter shot on the right side, you don’t need to insert as deep to ensure the catheter lies parallel to the vessel wall. Left sided lines should avoid Zone B because the catheter tip has a higher likelihood of irritating the lateral wall of the SVC.
zones
I was looking for a nice diagram indicating the optimal depths for each central line site (RIJ, LIJ, Subclavian, Femoral), but there actually isn’t a great one out there. I realize the reason for this is because patients come in all shapes and sizes. Well, mostly the same shape, but definitely different sizes (see picture below). If you insist on some numbers, a right-sided line can often be somewhere from 15-18. A left-sided line often can be up to 20. Consider whether your patient is a short elderly woman or a tall NBA player. These can vary significantly. Once you do a few with the same CVC kit but a few different sized patients, you get a much better sense of how deep you should be placing them.
For more tips and tricks on getting a great central line placement, check out EMCrit’s central line page.
Sources