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Search Results: 1 - 10 of 641 matches for " Armand RJ Girbes "
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Interfacing the ICU with the general practitioner
Armand RJ Girbes, Albertus Beishuizen
Critical Care , 2010, DOI: 10.1186/cc9066
Abstract: Admission to the intensive care unit (ICU) is only part of the course that a patient makes during their illness. Intensive care is not a gatekeeper speciality and patients therefore generally have their first contact in a hospital with emergency physicians, surgeons, internists, cardiologists, and so forth.After discharge from the ICU, most patients will return to the gatekeeper speciality - surgery, internal medicine, or the like. Following discharge from the hospital, patients will return to their homes and therefore the contact with their lifetime physician from their home situation, the general practitioner (GP), is of utmost impor tance. This is even more relevant when coordination of care from different specialists is required. The GP is also expected to have longstanding knowledge of the home situation of the patient. Whenever decisions in terms of end-of-life decisions have to be taken during ICU admission, the intensivist should be well informed. Not only is medical professional judgement important, but also the will and wishes of the patient. To gather all this information, the intensivist should contact doctors who have been involved in the treatment of the patient so far, including the GP, as well as the patient and relatives if possible. It should therefore be stressed as crucial that treating intensivists have (regular) contact with GPs.Etesse and colleagues report in the present issue of Critical Care about the relationship between GPs and intensivists in a part of southeastern France [1]. The authors mailed an anonymous questionnaire to over 7,000 GPs in their region. The response rate was very low (20%) and this will influence the results and conclusion. However, the results were devastating. Only one-half of the GPs rated their contact with the intensivist (on a scale from 1 to 100) at >57, and only 25% rated as >77. The conclusion that GPs are not very satisfied by communication with intensivists is therefore an under statement. To which extent th
Is routine autopsy in the intensive care unit viable?
Armand RJ Girbes, Jan G Zijlstra
Critical Care , 2010, DOI: 10.1186/cc9069
Abstract: Many of the discussions between clinician and pathologist deal with the question 'with' or 'because of' and 'post aut propter'. Is the pulmonary embolism or the pneumonia a perimortal phenomenon not searched for in the setting aiming for comfort, or is one or the other really the missed cause of death? Clinicians, correctly, do not always consider the pathologist to be the gold standard.In the era of evidence-based medicine, we diagnose and treat patients according to guidelines. These are based on extensive literature searches and consensus. How do we fit in the results of one autopsy? Autopsy will always be a nonrandom sample from a small selected population. It seems to have the evidence-based medicine grading of case reports. Undoubtedly, autopsy can be an important tool in research and it can be offered to families that have serious remaining questions. But routine autopsy is a 'dead man walking'.ICU: intensive care unit.The authors declare that they have no competing interests.
Severe electrolyte disorders following cardiac surgery: a prospective controlled observational study
Kees H Polderman, Armand RJ Girbes
Critical Care , 2004, DOI: 10.1186/cc2973
Abstract: Levels of magnesium, phosphate, potassium, calcium and sodium were measured in 500 consecutive patients undergoing various cardiac surgical procedures who required extracorporeal circulation (group 1). A total of 250 patients admitted to the intensive care unit following other major surgical procedures served as control individuals (group 2). Urine electrolyte excretion was measured in a subgroup of 50 patients in both groups.All cardiac patients received 1 l cardioplegia solution containing 16 mmol potassium and 16 mmol magnesium. In addition, intravenous potassium supplementation was greater in cardiac surgery patients (mean ± standard error: 10.2 ± 4.8 mmol/hour in cardiac surgery patients versus 1.3 ± 1.0 in control individuals; P < 0.01), and most (76% versus 2%; P < 0.01) received one or more doses of magnesium (on average 2.1 g) for clinical reasons, mostly intraoperative arrhythmia. Despite these differences in supplementation, electrolyte levels decreased significantly in cardiac surgery patients, most of whom (88% of cardiac surgery patients versus 20% of control individuals; P < 0.001) met criteria for clinical deficiency in one or more electrolytes. Electrolyte levels were as follows (mmol/l [mean ± standard error]; cardiac patients versus control individuals): phosphate 0.43 ± 0.22 versus 0.92 ± 0.32 (P < 0.001); magnesium 0.62 ± 0.24 versus 0.95 ± 0.27 (P < 0.001); calcium 1.96 ± 0.41 versus 2.12 ± 0.33 (P < 0.001); and potassium 3.6 ± 0.70 versus 3.9 ± 0.63 (P < 0.01). Magnesium levels in patients who had not received supplementation were 0.47 ± 0.16 mmol/l in group 1 and 0.95 ± 0.26 mmol/l in group 2 (P < 0.001). Urinary excretion of potassium, magnesium and phosphate was high in group 1 (data not shown), but this alone could not completely account for the observed electrolyte depletion.Patients undergoing cardiac surgery with extracorporeal circulation are at high risk for electrolyte depletion, despite supplementation of some electrolytes, such as
Novel applications of therapeutic hypothermia: report of three cases
Koen J Hartemink, Willem Wisselink, Jan A Rauwerda, Armand RJ Girbes, Kees H Polderman
Critical Care , 2004, DOI: 10.1186/cc2928
Abstract: Evidence from a large number of animal studies and clinical trials strongly suggests that mild (32-34°C) hypothermia can have neuroprotective effects in various situations of imminent or actual neurological injury [1-12]. Protective effects of therapeutic hypothermia have been clearly demonstrated in patients with postanoxic coma after cardiopulmonary resuscitation (CPR) [1-4]. Other categories of patients that could benefit from therapeutic hypothermia include patients with traumatic brain injury [1,2,5-8], stroke [9,10], subarachnoid haemorrhage [11,12], and fever, in patients with neurological injury [13-15], although the evidence is less clear-cut than for patients with postanoxic injury [1-4]. In addition, there is some evidence from animal and small clinical studies that induced hypothermia may also have cardioprotective effects after ischaemic cardiac events [16,17].Hypothermia is also used during various surgical procedures, including major vascular surgery [1,18-20]. Cooling is thought to provide spinal cord protection as well as overall neuroprotection in the latter category of patients. In the present article we describe three exceptional cases of neurological injury. Although each of these three patients had a rare and unusual cause of injury, their clinical situations nevertheless were in many aspects similar to those where therapeutic hypothermia has been shown to be, or is thought to be, effective. We therefore decided to treat these patients with artificial cooling to prevent postischaemic neurological injury.Patient A, a 49-year-old man with no significant medical history, was admitted to another hospital after being stabbed in his neck. He was transferred to our centre for emergency surgery, which was started nearly 1 hour following the incident. Surgical exploration showed a dissection of the left internal carotid artery and a complete transsection of the left internal jugular vein and vagal nerve. Haemostasis and anastomosis of the artery was ach
Clinical review: Treatment of new-onset atrial fibrillation in medical intensive care patients: a clinical framework
Mengalvio E Sleeswijk, Trudeke Van Noord, Jaap E Tulleken, Jack JM Ligtenberg, Armand RJ Girbes, Jan G Zijlstra
Critical Care , 2007, DOI: 10.1186/cc6136
Abstract: Atrial fibrillation (AF) is frequently observed in the medical intensive care unit (MICU) [1], with up to about 15% of MICU patients showing periods of AF [2-4]. AF directly leads to loss of the atrial kick and, as a consequence, reduces ventricular loading. Especially if the ventricular compliance is decreased, as is the case in sepsis and many other medical conditions, this reduction results in decreased cardiac performance. By performance, we mean the capacity to meet pressure and volume requirements. The irregular and mostly rapid ventricular response also shortens the ventricular filling time, and thereby shortens the preload. AF therefore reduces cardiac performance. The reduction is more serious in patients with pre-existing cardiac dysfunction due to decreased ventricular compliance. A persistent high ventricular rate may lead to tachycardia-mediated cardiomyopathy [5]. Conversion to sinus rhythm (SR) improves ventricular function in patients with heart failure [6]. These findings urge most intensivists to treat AF.Most intensivists may have adopted an AF treatment modality based on their individual experience combined with extrapolation of the treatment of other, mostly unrelated, but well-defined and well-established, patient groups. In most cases this means that, after correction of assumed or perpetuating factors, treatment directly aimed at the rhythm disorder itself will be started. To date, treatment of AF in the MICU cannot be supported by sufficient evidence from the literature. Notwithstanding the large number of patients involved, thorough research in this field is scarce [7]. There are important reasons to believe that MICU patients are different from other patients with AF and therefore require a more tailored therapy. Fundamental questions that remain unanswered for MICU patients are summarised in Table 1.To find answers for these questions we searched for direct clinical evidence and – when not available – searched for evidence from related ar
Hospital-acquired sinusitis is a common cause of fever of unknown origin in orotracheally intubated critically ill patients
Arthur RH van Zanten, J Mark Dixon, Martine D Nipshagen, Remco de Bree, Armand RJ Girbes, Kees H Polderman
Critical Care , 2005, DOI: 10.1186/cc3805
Abstract: Sinus X-rays (SXRs) were performed in all patients with fever for which an initial screening (physical examination, microbiological cultures and chest X-ray) revealed no obvious cause. All patients were followed with a predefined protocol, including antral drainage in all patients with abnormal or equivocal results on their SXR.Initial screening revealed probable causes of fever in 153 of 351 patients (43.6%). SXRs were taken in the other 198 patients (56.4%); 129 had obvious or equivocal abnormalities. Sinus drainage revealed purulent material and positive cultures (predominantly Pseudomonas and Klebsiella species) in 84 patients. Final diagnosis for the cause of fever in all 351 patients based on X-ray results, microbiological cultures, and clinical response to sinus drainage indicated sinusitis as the sole cause of fever in 57 (16.2%) and as contributing factor in 48 (13.8%) patients with FUO. This will underestimate the actual incidence because SXR and drainage were not performed in all patients.Physicians treating critically ill patients should be aware of the high risk of sinusitis and take appropriate preventive measures, including the removal of nasogastric tubes in patients requiring long-term mechanical ventilation. Routine investigation of FUO should include computed tomography scan, SXR or sinus ultrasonography, and drainage should be performed if any abnormalities are found.A large proportion of patients admitted to the intensive care unit (ICU) are likely to develop fever of unknown origin (FUO) at some point of their stay there. Many of these episodes are due to well-recognised hospital-acquired infections such as ventilator-associated pneumonia (VAP) and central venous catheter infections [1,2]. Various diagnostic strategies have been developed to handle such infectious complications in the ICU, many of which have been laid down in hospital or national guidelines [3,4]. However, the potential role of sinusitis as a source of hospital-acquired infecti
Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: a prospective observational cohort study
Rob JM Strack van Schijndel, Peter JM Weijs, Rixt H Koopmans, Hans P Sauerwein, Albertus Beishuizen, Armand RJ Girbes
Critical Care , 2009, DOI: 10.1186/cc7993
Abstract: This was a prospective observational cohort study in a mixed medical-surgical, 28-bed ICU in an academic hospital. 243 sequential mixed medical-surgical patients were enrolled on day 3–5 after admission if they had an expected stay of at least another 5–7 days. They underwent indirect calorimetry as part of routine care. Nutrition was guided by the result of indirect calorimetry and we aimed to provide at least 1.2 g of protein/kg/day. Cumulative balances were calculated for the period of mechanical ventilation. Outcome parameters were ICU, 28-day and hospital mortality.In women, when corrected for weight, height, Apache II score, diagnosis category, and hyperglycaemic index, patients who reached their nutritional goals compared to those who did not, showed a hazard ratio (HR) of 0.199 for ICU mortality (CI 0.048–0.831; P = 0.027), a HR of 0.079 for 28 day mortality (CI 0.013–0.467; P = 0.005) and a HR of 0.328 for hospital mortality (CI 0.113–0.952; P = 0.04). Achievement of energy goals whilst not reaching protein goals, did not affect ICU mortality; the HR for 28 day mortality was 0.120 (CI 0.027–0.528; P = 0.005) and 0.318 for hospital mortality (CI 0.107–0.945; P = 0.039). No difference in outcome related to optimal feeding was found for men.Optimal nutritional therapy improves ICU, 28-day and hospital survival in female ICU patients. Female patients reaching both energy and protein goals have better outcomes than those reaching only the energy goal. In the present study men did not benefit from optimal nutrition.Nutrition is an integral and important part of therapy in the ICU. Nutritional therapy aims at conservation or restoration of the body protein mass and of provision of adequate amounts of energy. On a hypothetical basis, surrogate markers for optimal nutrition with regard to energy and protein provision have proposed to be the delivery of energy as measured by indirect calorimetry, and provision of 1.2 to 1.5 g of protein per kg of pre-admission weight
Predicting outcome of rethoracotomy for suspected pericardial tamponade following cardio-thoracic surgery in the intensive care unit
Birkitt L ten Tusscher, Johan AB Groeneveld, Otto Kamp, Evert K Jansen, Albertus Beishuizen, Armand RJ Girbes
Journal of Cardiothoracic Surgery , 2011, DOI: 10.1186/1749-8090-6-79
Abstract: Twenty-one consecutive patients undergoing rethoracotomy for suspected pericardial tamponade in the ICU, admitted after primary cardio-thoracic surgery, were identified for this retrospective study. We compared patients with or without a decrease in severe haemodynamic compromise after rethoracotomy, according to the cardiovascular component of the sequential organ failure assessment (SOFA) score.A favourable haemodynamic response to rethoracotomy was observed in 11 (52%) of patients and characterized by an increase in cardiac output, and less fluid and norepinephrine requirements. Prior to surgery, the absence of treatment by heparin, a minimum cardiac index < 1.0 L/min/m2 and a positive fluid balance (> 4,683 mL) were predictive of a beneficial haemodynamic response. During surgery, the evacuation of clots and > 500 mL of pericardial fluid was associated with a beneficial haemodynamic response. Echocardiographic parameters were of limited help in predicting the postoperative course, even though 9 of 13 pericardial clots found at surgery were detected preoperatively.Clots and fluids in the pericardial space causing regional tamponade and responding to surgical evacuation after primary cardio-thoracic surgery, are difficult to diagnose preoperatively, by clinical, haemodynamic and even echocardiographic evaluation in the ICU. Only absence of heparin treatment, a large positive fluid balance and low cardiac index predicted a favourable haemodynamic response to rethoracotomy. These data might help in deciding and timing of reinterventions after primary cardio-thoracic surgery.Whereas pericardial effusion is relatively common and may not require drainage, pericardial tamponade is a rare but potentially life-threatening complication after cardio-thoracic surgery and opening of the pericardium [1-11]. Recognition is difficult or late because tamponade is often regional rather than circumferential, contributing to relatively non-classical and non-specific findings [3-5,9,
Malabsorption and nutritional balance in the ICU: fecal weight as a biomarker: a prospective observational pilot study
Nicolette J Wierdsma, Job HC Peters, Peter JM Weijs, Martjin B Keur, Armand RJ Girbes, Ad A van Bodegraven, Albertus Beishuizen
Critical Care , 2011, DOI: 10.1186/cc10530
Abstract: This was an observational pilot study in a tertiary mixed medical-surgical ICU in hemodynamically stable adult ICU patients, without clinically evident gastrointestinal malfunction. Fecal weight (grams/day), fecal energy (by bomb calorimetry in kcal/day), and macronutrient content (fat, protein, and carbohydrate in grams/day) were measured. Diagnostic accuracy expressed in terms of test sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and receiver operator curves (ROCs) were calculated for fecal weight as a marker for energy malabsorption. Malabsorption was a priori defined as < 85% intestinal absorption capacity.Forty-eight patients (63 ± 15 years; 58% men) receiving full enteral feeding were included. A cut-off fecal production of > 350 g/day (that is, diarrhea) was linked to the optimal ROC (0.879), showing a sensitivity and PPV of 80%, respectively. Specificity and NPV were both 96%. Fecal weight (grams/day) and intestinal energy-absorption capacity were inversely correlated (r = -0.69; P < 0.001). Patients with > 350 g feces/day had a significantly more-negative energy balance compared with patients with < 350 g feces/day (loss of 627 kcal/day versus neutral balance; P = 0.012).A fecal weight > 350 g/day in ICU patients is a biomarker applicable in daily practice, which can act as a surrogate for fecal energy loss and intestinal energy absorption. Daily measurement of fecal weight is a feasible means of monitoring the nutritional status of critically ill patients and, in those identified as having malabsorption, can monitor responses to changes in dietary management.A persistent negative energy balance, known as protein-energy malnutrition (PEM), depletes lean tissue and adipose mass. In critically ill patients, PEM is strongly correlated with complications, especially infections [1]. In general, malnutrition in critically ill patients is associated with impaired immune function, an increased risk of infections, and an increased mor
Steroidogenesis in the adrenal dysfunction of critical illness: impact of etomidate
Nienke Molenaar, Ronald M Bijkerk, Albertus Beishuizen, Christel M Hempen, Margriet FC de Jong, Istvan Vermes, Gertjan van der Sluijs Veer, Armand RJ Girbes, AB Johan Groeneveld
Critical Care , 2012, DOI: 10.1186/cc11415
Abstract: This was a prospective study in a mixed surgical/medical intensive care unit (ICU) of a university hospital. The patients were 62 critically ill patients with a clinical suspicion of CIRCI. The patients underwent a 250-μg ACTH test (n = 67). ACTH, adrenal steroids, substrates, and precursors (modified tandem mass spectrometry) also were measured. Clinical characteristics including use of etomidate to facilitate intubation (n = 14 within 72 hours of ACTH testing) were recorded.At the time of ACTH testing, patients had septic (n = 43) or nonseptic critical illness (n = 24). Baseline cortisol directly related to sepsis and endogenous ACTH, independent of etomidate use. Etomidate was associated with a lower baseline cortisol and cortisol/11β-deoxycortisol ratio as well as higher 11β-deoxycortisol, reflecting greater 11β-hydroxylase inhibition in nonsepsis than in sepsis. Cortisol increases < 250 mM in exogenous ACTH were associated with relatively low baseline (HDL-) cholesterol, and high endogenous ACTH with low cortisol/ACTH ratio, independent of etomidate. Although cortisol increases with exogenous ACTH, levels were lower in sepsis than in nonsepsis patients, and etomidate was associated with diminished increases in cortisol with exogenous ACTH, so that its use increased, albeit nonsignificantly, low cortisol increases to exogenous ACTH from 38% to 57%, in both conditions.A single dose of etomidate may attenuate stimulated more than basal cortisol synthesis. However, it may only partly contribute, particularly in the stressed sepsis patient, to the adrenal dysfunction of CIRCI, in addition to substrate deficiency.Activation of the hypothalamic-pituitary-adrenal (HPA) axis serves to adapt the organism to stress during critical illness, which may be differently regulated in sepsis and nonsepsis [1-7]. Particularly in septic shock, elevated levels of cortisol may be too low for the high level of stress, as compared with those in nonseptic critical illness. This may be a
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