The University of Bordeaux and University Hospital of Bordeaux supported this publication.

The protocol has been approved by the human research ethics committee of the University Hospital of Bordeaux.
NOTE: The protocol described in this section involves evaluation of ADL dependence using the Katz ADL. The six activities assessed are described above18. The Katz ADL is administered at the Bordeaux University Hospital, on admission and discharge, to all patients over 75 years of age, i.e., all those in acute geriatric medicine wards. Inpatients in geriatric units present with numerous comorbidities and it is recommended that staff assess all such patients. In theory, the Katz ADL could be administered to all patients at risk of losing their independence due to an acute medical problem, which would include some younger patients. However, ADL dependence is infrequent in younger adults, as the prevalence of disabling diseases is low in that population. Nevertheless, the protocol could also be implemented in other departments, particularly internal medicine, cardiology, and neurology.
1. Protocol for administering the Katz ADL before hospitalization
<ol>
	<li>Evaluate bathing activity.
	<ol>
		<li>To evaluate bathing, ask patients how they bathe and whether they need someone to help them with bathing. If so, ask them which part of the body they require help with. Then, note whether they are independent (1 point) or dependent (0 point) in bathing activities. 
		NOTE: Independent patients bathe their entire body alone, with the exception of the back, genital area, or a disabled extremity. Dependent patients need help to bathe several parts of their body, or to get in and out of the shower or bathtub.</li>
	</ol>
	</li>
	<li>Evaluate dressing.
	<ol>
		<li>Ask patients whether they can dress and undress alone, and whether they can take their clothes out of the closet without help. Ask whether they need help with putting on socks or other items of clothing. Then, note whether they are independent (1 point) or dependent (0 point) in dressing activities. 
		NOTE: An independent person gets their clothes out of the closet and puts them on, including fastening them where applicable. Shoe tying is not included among dressing activities. A dependent person needs some help with dressing or needs to be completely dressed by someone else.</li>
	</ol>
	</li>
	<li>Evaluate toileting.
	<ol>
		<li>Ask patients whether they go to the toilet unassisted at home. Ask whether they can sit down and stand up from the toilet, arrange their clothing as needed, and clean the genital area without help. Then, note whether they are independent (1 point) or dependent (0 point) in toileting. 
		NOTE: An independent person goes to the toilet, sits and stands up from the toilet, arranges clothes, and cleans the genital area without help. A dependent person needs help transferring to the toilet and cleaning up, or uses a bedpan or commode.</li>
	</ol>
	</li>
	<li>Evaluate transferring.
	<ol>
		<li>Ask patients whether they can move from the bed to a chair, and from a chair to the bed, without human assistance. Then, note whether they are independent (1 point) or dependent (0 point) in transferring. 
		NOTE: An Independent person moves into or out of a bed or chair unassisted or using a mechanical transferring aid. A dependent individual needs help from another person to move from a bed to a chair or requires a complete transfer.</li>
	</ol>
	</li>
	<li>Evaluate continence.
	<ol>
		<li>Ask patients whether they have complete self-control over urination and defecation. If not, ask whether they can use a urinary catheter or diaper without help. Then, note whether they are independent (1 point) or dependent (0 point) with respect to continence. 
		NOTE: Independent patients exercise complete self-control over urination and defecation, or use a urinary catheter or diapers without help. The dependent person is partially or totally incontinent (bowel or bladder) and needs help to manage these functions.</li>
	</ol>
	</li>
	<li>Evaluate feeding.
	<ol>
		<li>Ask patients whether they eat without help; if so, ask whether they are able to cut meat or open the lid of a yogurt container. Then, note whether they are independent (1 point) or dependent (0 point) in feeding activities. An independent person can eat a prepared and delivered meal without assistance. 
		NOTE: An independent person transfers food from the plate into the mouth without help. A dependent person needs partial or total help with feeding.</li>
	</ol>
	</li>
	<li>Calculate the ADL score by summing the scores for all activities.</li>
</ol>
2. Administration of ADL scale on hospital admission
<ol>
	<li>Bathing
	<ol>
		<li>During the first day of hospitalization, offer patients a shower. If they feel able to take one, accompany them to the bathroom and check whether they are able to wash by themselves. If patients do not feel able to do this, offer to wash them in bed or at the basin.</li>
		<li>Observe whether patients are able to do this on their own or whether they need guidance or help with certain parts of the body. Then, note whether they are independent or dependent in bathing (following the same definition of independent and dependent as in step 1.1).</li>
	</ol>
	</li>
	<li>Dressing
	<ol>
		<li>During the first day of hospitalization, propose that patients get dressed. Ask them to choose clothes from the closet and put them on; if patients have difficulty, help them to get dressed.</li>
		<li>In the evening, follow the same procedure, but as applied to undressing.</li>
		<li>Note whether the patient is independent or dependent in dressing (following the same definition of independent and dependent as in step 1.2).</li>
	</ol>
	</li>
	<li>Toileting
	<ol>
		<li>During the first few days of hospitalization, check whether patients are able to go to the toilet alone, sit and stand up from the toilet, arrange their clothing, and clean the genital area.</li>
		<li>Evaluate whether a commode or bedpan is needed. Note whether patients are independent or dependent in toileting (following the same definition of independent and dependent as in step 1.3).</li>
	</ol>
	</li>
	<li>Transferring
	<ol>
		<li>On the first day of hospitalization, ask patients to transfer from the bed to a chair and from the chair to the bed. If patients have any difficulty, first offer mechanical transferring aids, and if necessary, help them to make the transfer. Then, note whether patients are independent or dependent for transferring (following the same definition of independent and dependent as in step 1.4).</li>
	</ol>
	</li>
	<li>Feeding
	<ol>
		<li>During the first meal at the hospital, observe whether patients are able to eat alone, including cutting meat and opening the lid of a yogurt container. Help them if necessary. Then, note whether the patient is independent or dependent for eating (following the same definition of independent and dependent as in step 1.6).</li>
	</ol>
	</li>
	<li>Calculate the ADL score by summing the scores for all activities.</li>
</ol>
3. Compare functional independence scores before the acute medical problem and at the time of hospital admission
<ol>
	<li>Identify the activities in which patients have lost independence during the acute medical problem. Identify activities in which patients were dependent prior to the problem.</li>
	<li>Encourage patients to regain their lost independence through rehabilitative care.</li>
	<li>Help to maintain any independence that was not lost during the acute medical problem.</li>
</ol>
4. Recalculate ADL score throughout hospitalization (twice per week)
<ol>
	<li>Perform the same assessment steps described in Step 2.</li>
	<li>Discuss the assessment results during a staff meeting where nurses, nurse assistants, physicians, and physiotherapists are present.</li>
	<li>Compare ADL scores to identify improvement or deterioration of functional independence.</li>
	<li>Maintain or modify rehabilitative care according to the evolution of functional independence; the goal is for patients to recover their former level of independence.</li>
</ol>
5. Evaluate the ADL score at discharge and compare it to the score prior to hospitalization
<ol>
	<li>Determine whether patients have lost functional independence as a result of the acute medical problem.</li>
	<li>Adapt the home help protocol as needed.</li>
</ol>

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The authors have no conflicts of interest to disclose.

The protocol is not appropriate in all situations 
Our protocol was designed for patients who have been hospitalized for an acute medical problem. However, other tools, such as the Barthel Index, should be used in rehabilitation centers. The original Katz ADL scale scores functional ability only on a 7-point scale (scores of 0&#8211;6); subtle fluctuations in functional dependence may therefore be overlooked. The Barthel Index, which is generally comparable to the Katz ADL, yields weighted and summe...

Medical problems can cause older people to lose functional independence, rendering them unable to carry out activities of daily living (ADL) without assistance from others. This loss of independence, which often results from cardiovascular comorbidities1, cognitive impairment2,3, and visual impairment4, impacts patient quality of life5 and life expectancy6, and increases healthcare costs7. Functional independence may progressively deteriorate, or be lost completely, with more severe comorbidities (cognitive impairment, heart failure, etc.). It may also worsen during an acute medical problem, such as stroke, myocardial infarction, lower limb fracture, or chest infection8. About 30% of patients aged between 70 and 80 years, and 60% of those aged over 80 years, experience such a loss of independence during hospitalization9,10. Patients may recover the functional independence they enjoyed prior to the acute medical problem, or it may persist thereafter despite appropriate treatment.
It is widely accepted that treatment aimed at maintaining or restoring functional independence during hospitalization for an acute medical problem is most effective if it is started as soon as possible11. Physical exercise during hospitalization improves function in the short and medium term12,13. In a hospitalized population, scores on measures of ADL were associated with muscle oxidative capacity and muscle function1. Hence, assessing a patient&#39;s functional independence at an early stage of hospitalization is a priority; this assessment should then be compared with the patient&#39;s level of ADL independence before hospitalization (baseline). Medical care, particularly nursing care, is aimed at restoring any loss of independence or maintaining the existing level thereof. This requires a reliable and reproducible assessment method; the most commonly used measure for this purpose is the Katz Index of Independence in Activities of Daily Living (Katz ADL).
The Katz ADL, developed in 1970, allows assessment of a patient&#8217;s ability to carry out basic ADL independently15,16. The scale measures patient independence in six activities: bathing, dressing, toileting, transferring, continence, and feeding. Each activity is scored as 0 or 1, where a score of 0 indicates dependence on another person, and 1 indicates independence. A total Katz ADL score of 6 denotes full independence, a score of 4 moderate dependence, and a score of 2 or less severe dependence.
For many years, the Katz ADL has proven useful in the assessment of functional status in older people. First, the Katz ADL assessment is very simple to perform and involves interviewing the patient or family members about the patient&#8217;s ability to perform the six ADL activities, or directly observing how well the patient performs these activities17. Furthermore, during an acute medical problem, the Katz ADL Index is sensitive to major, but not to minor, changes in health status. Thus, this tool is ideal for assessing the impact of an acute medical problem on patients&#8217; functional status, whatever their chronic morbidities.
When initiating rehabilitation within the first days of an acute medical problem, it is necessary to determine the extent of the patient&#8217;s functional decline. For this purpose, we propose that the functional status of each patient should be assessed before hospitalization via interview, and that the ability to perform ADL be assessed within the first days of hospitalization via observation. These two assessments could guide early preventive and rehabilitative measures in parallel with a care plan for the acute event. The effectiveness of these measures for promoting recovery of functional independence can be monitored by repeated ADL assessment until discharge.

<table>
	<tbody>
		<tr>
			<td>Clothing and underwear</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Hospital Bathroom with toilet</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Meal Tray</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Medical Bed</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Medical Chair</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Papers</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Pens</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Table Bed</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

assessment of dependence in activities of daily living among older patients in an acute care unit

During an acute medical problem, older people may lose functional independence. ADL scales are used to assess this loss of independence. The simplest and most convenient ADL scale is the Katz Index, which measures six ADL: bathing, dressing, toileting, transferring, continence, and feeding. A lower ADL score indicates greater loss of functional independence. The ADL score prior to the acute medical problem (baseline) is estimated by questioning the patient or the caregivers, and this score is then compared with that on hospital admission. The ADL score should be monitored from hospital admission until discharge to allow early detection of changes in functional independence. Identifying any loss of functional independence before and during hospitalization provides information to caregivers regarding the risk of short-term mortality risk and complications, and the prognosis after hospitalization.

Here, we consider two example cases after completion of the protocol: one with full recovery of the baseline level of ADL function at discharge, and one with no or partial recovery.
Discharged with baseline level of ADL function 
In this group of patients, two ADL function trajectories were possible, as shown in Figure 1: patients who maintained their ADL score throughout hospitalization (Trajectory A) and those whose score at hospitalization...

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Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

During acute medical problems, older people may lose independence in activities of daily living (ADL). Assessment of baseline ADL and ADL on admission can guide personalized treatment plans aimed at preventing nosocomial dependence and ensuring better functional outcomes.

During an acute medical problem, older people may lose functional independence. ADL scales are used to assess this loss of independence. The simplest and ...

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9.5K Views.  CHU Bordeaux. During acute medical problems, older people may lose independence in activities of daily living (ADL). Assessment of baseline ADL and ADL on admission can guide personalized treatment plans aimed at preventing nosocomial dependence and ensuring better functional outcomes.

Video: Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

Expired CO2 Measurement in Intubated or Spontaneously Breathing Patients from the Emergency Department

Carbon dioxide (CO2) along with oxygen (O2) share the role of being the most important gases in the human body. The measuring of expired CO2 at the mouth has solicited growing clinical interest among physicians in the emergency department for various indications: (1) surveillance et monitoring of the intubated patient; (2) verification of the correct positioning of an endotracheal tube; (3) monitoring of a patient in cardiac arrest; (4) achieving normocapnia in intubated head trauma patients; (5) monitoring ventilation during procedural sedation. The video allows physicians to familiarize themselves with the use of capnography and the text offers a review of the theory and principals involved. In particular, the importance of CO2 for the organism, the relevance of measuring expired CO2, the differences between arterial and expired CO2, the material used in capnography with their artifacts and traps, will be reviewed. Since the main reluctance in the use of expired CO2 measurement is due to lack of correct knowledge concerning the physiopathology of CO2 by the physician, we hope that this explanation and the video sequences accompanying will help resolve this limitation.

Expired CO2 Measurement in Intubated or Spontaneously Breathing Patients from the Emergency Department

This video describes how to perform CO2 measurement in intubated as well as spontaneously breathing patients. The main clinical indications refer to emergency situations: (1) verifying adequate positioning of an endotracheal tube; (2) achieving normocapnia in trauma patients; (3) monitoring ventilation in the case of procedural sedation.

Carbon dioxide (CO2) along with oxygen (O2) share the role of being the most important gases in the human body. The measuring of expired CO2 at the mouth ...

Driving Simulation in the Clinic: Testing Visual Exploratory Behavior in Daily Life Activities in Patients with Visual Field Defects

Patients suffering from homonymous hemianopia after infarction of the posterior cerebral artery (PCA) report different degrees of constraint in daily life, despite similar visual deficits. We assume this could be due to variable development of compensatory strategies such as altered visual scanning behavior. Scanning compensatory therapy (SCT) is studied as part of the visual training after infarction next to vision restoration therapy. SCT consists of learning to make larger eye movements into the blind field enlarging the visual field of search, which has been proven to be the most useful strategy1, not only in natural search tasks but also in mastering daily life activities2. Nevertheless, in clinical routine it is difficult to identify individual levels and training effects of compensatory behavior, since it requires measurement of eye movements in a head unrestrained condition. Studies demonstrated that unrestrained head movements alter the visual exploratory behavior compared to a head-restrained laboratory condition3. Martin et al.4 and Hayhoe et al.5 showed that behavior demonstrated in a laboratory setting cannot be assigned easily to a natural condition. Hence, our goal was to develop a study set-up which uncovers different compensatory oculomotor strategies quickly in a realistic testing situation: Patients are tested in the clinical environment in a driving simulator. SILAB software (Wuerzburg Institute for Traffic Sciences GmbH (WIVW)) was used to program driving scenarios of varying complexity and recording the driver's performance. The software was combined with a head mounted infrared video pupil tracker, recording head- and eye-movements (EyeSeeCam, University of Munich Hospital, Clinical Neurosciences).
The positioning of the patient in the driving simulator and the positioning, adjustment and calibration of the camera is demonstrated. Typical performances of a patient with and without compensatory strategy and a healthy control are illustrated in this pilot study. Different oculomotor behaviors (frequency and amplitude of eye- and head-movements) are evaluated very quickly during the drive itself by dynamic overlay pictures indicating where the subjects gaze is located on the screen, and by analyzing the data. Compensatory gaze behavior in a patient leads to a driving performance comparable to a healthy control, while the performance of a patient without compensatory behavior is significantly worse. The data of eye- and head-movement-behavior as well as driving performance are discussed with respect to different oculomotor strategies and in a broader context with respect to possible training effects throughout the testing session and implications on rehabilitation potential.

Patients with visual deficits after stroke report about different constraints in daily life most likely due to variable compensatory strategies, which are difficult to differentiate in clinical routine. We present a clinical set-up which allows measurement of different compensatory head- and eye-movement-strategies and evaluating their effects on driving performance.

Patients suffering from homonymous hemianopia after infarction of the posterior cerebral artery (PCA) report different degrees of constraint in daily ...

Collecting Saliva and Measuring Salivary Cortisol and Alpha-amylase in Frail Community Residing Older Adults via Family Caregivers

Salivary measures have emerged in bio-behavioral research that are easy-to-collect, minimally invasive, and relatively inexpensive biologic markers of stress. This article we present the steps for collection and analysis of two salivary assays in research with frail, community residing older adults-salivary cortisol and salivary alpha amylase. The field of salivary bioscience is rapidly advancing and the purpose of this presentation is to provide an update on the developments for investigators interested in integrating these measures into research on aging. Strategies are presented for instructing family caregivers in collecting saliva in the home, and for conducting laboratory analyses of salivary analytes that have demonstrated feasibility, high compliance, and yield quality specimens. The protocol for sample collection includes: (1) consistent use of collection materials; (2) standardized methods that promote adherence and minimize subject burden; and (3) procedures for controlling certain confounding agents. We also provide strategies for laboratory analyses include: (1) saliva handling and processing; (2) salivary cortisol and salivary alpha amylase assay procedures; and (3) analytic considerations.

We demonstrate: (1) procedures for collection of salivary samples in cognitive impaired older adults by family caregivers in the home setting, (2) procedures for measuring stress activity via salivary cortisol and alpha amylase, and (3) representative profiles. Protocols that allow researchers to study stress-linked processes advance our understanding of biological sensitivity and susceptibility.

Salivary measures have emerged in bio-behavioral research  that are easy-to-collect, minimally invasive, and relatively inexpensive  biologic markers of ...

Clinical Assessment of Spatiotemporal Gait Parameters in Patients and Older Adults

Spatial and temporal characteristics of human walking are frequently evaluated to identify possible gait impairments, mainly in orthopedic and neurological patients1-4, but also in healthy older adults5,6. The quantitative gait analysis described in this protocol is performed with a recently-introduced photoelectric system (see&#160;Materials table) which has the potential to be used in the clinic because it is portable, easy to set up (no subject preparation is required before a test), and does not require maintenance and sensor calibration. The photoelectric system consists of series of high-density floor-based photoelectric cells with light-emitting and light-receiving diodes that are placed parallel to each other to create a corridor, and are oriented perpendicular to the line of progression7. The system simply detects interruptions in light signal, for instance due to the presence of feet within the recording area. Temporal gait parameters and 1D spatial coordinates of consecutive steps are subsequently calculated to provide common gait parameters such as step length, single limb support and walking velocity8, whose validity against a criterion instrument has recently been demonstrated7,9. The measurement procedures are very straightforward; a single patient can be tested in less than 5 min&#160;and a comprehensive report can be generated in less than 1&#160;min.

This protocol is used to evaluate spatial and temporal gait variables of neurological/orthopedic patients and older persons by means of a recently-introduced floor-based photocell system.

Spatial and temporal characteristics of human walking are frequently evaluated to identify possible gait impairments, mainly in orthopedic and ...

A Method for Quantifying Upper Limb Performance in Daily Life Using Accelerometers

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. It has become important to measure a person's activities in daily life, and not just measure their capacity for activity in the structured environment of a clinic or laboratory. A wearable sensor that is now enabling measurement of daily movement is the accelerometer. Accelerometers are commercially-available devices resembling large wrist watches that can be worn throughout the day. Data from accelerometers can quantify how the limbs are engaged to perform activities in peoples' homes and communities. This report describes a methodology to collect accelerometry data and turn it into clinically-relevant information. First, data are collected by having the participant wear two accelerometers (one on each wrist) for 24 h or longer. The accelerometry data are then downloaded and processed to produce four different variables that describe key aspects of upper limb activity in daily life: hours of use, use ratio, magnitude ratio, and the bilateral magnitude. Density plots can be constructed that visually represent the data from the 24 h wearing period. The variables and their resultant density plots are highly consistent in neurologically-intact, community-dwelling adults. This striking consistency makes them a useful tool for determining if upper limb daily performance is different from normal. This methodology is appropriate for research studies investigating upper limb dysfunction and interventions designed to improve upper limb performance in daily life in people with stroke and other patient populations. Because of its relative simplicity, it may not be long before it is also incorporated in clinical neurorehabilitation practice.

This protocol describes a method to quantify upper limb performance in daily life using wrist-worn accelerometers.

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. ...

Objective Nociceptive Assessment in Ventilated ICU Patients: A Feasibility Study Using Pupillometry and the Nociceptive Flexion Reflex

The concept of objective nociceptive assessment and optimal pain management have gained increasing attention. Despite the known negative short- and long-term consequences of unresolved pain or excessive analgosedation, adequate nociceptive monitoring remains challenging in non-communicative, critically ill adults. In the intensive care unit (ICU), routine nociceptive evaluation is carried out by the attending nurse using the Behavior Pain Scale (BPS) in mechanically ventilated patients. This assessment is limited by medication use (e.g., neuromuscular blocking agents) and the inherent subjective character of nociceptive evaluation by third parties.
Here, we describe the use of two nociceptive reflex testing devices as tools for objective pain evaluation: the pupillary dilation reflex (PDR) and nociception flexion reflex (NFR). These measurement tools are non-invasive and well tolerated, providing clinicians and researchers with objective information regarding two different nociceptive processing pathways: (1)&#160;the pain-related autonomic reactivity&#160;and (2) the ascending component of the somatosensory system. The use of PDR and NFR measurements are currently limited to specialized pain clinics and research institutions because of impressions that these are technically demanding or time-consuming procedures, or even because of a lack of knowledge regarding their existence.
By focusing on the two abovementioned nociceptive reflex assessments, this study evaluated their feasibility as a physiological pain measurement method in daily practice. Pursuing novel technologies for evaluating the analgesia level in unconscious patients may further improve individual pharmacological treatment and patient related outcome measures. Therefore, future research must include large well-designed clinical trials in a real-life environment.

Pain assessment in anesthetized patients who cannot communicate with the outside world in any way remains challenging despite the development of innovative objective pain evaluation tools. In this project, the pupillary dilation reflex and the nociception flexion reflex are assessed in critically ill, mechanically ventilated adult patients.

The concept of objective nociceptive assessment and optimal pain management have gained increasing attention. Despite the known negative short- and ...

Halogenated Agent Delivery in Porcine Model of Acute Respiratory Distress Syndrome via an Intensive Care Unit Type Device

Acute respiratory distress syndrome (ARDS) is a common cause of hypoxemic respiratory failure and death in critically ill patients, and there is an urgent need to find effective therapies. Preclinical studies have shown that inhaled halogenated agents may have beneficial effects in animal models of ARDS. The development of new devices to administer halogenated agents using modern intensive care unit (ICU) ventilators has significantly simplified the dispensing of halogenated agents to ICU patients. Because previous experimental and clinical research suggested potential benefits of halogenated volatiles, such as sevoflurane or isoflurane, for lung alveolar epithelial injury and inflammation, two pathophysiologic landmarks of diffuse alveolar damage during ARDS, we designed an animal model to understand the mechanisms of the effects of halogenated agents on lung injury and repair. After general anesthesia, tracheal intubation, and the initiation of mechanical ventilation, ARDS was induced in piglets via the intratracheal instillation of hydrochloric acid. Then, the piglets were sedated with inhaled sevoflurane or isoflurane using an ICU-type device, and the animals were ventilated with lung-protective mechanical ventilation during a 4 h period. During the study period, blood and alveolar samples were collected to evaluate arterial oxygenation, the permeability of the alveolar-capillary membrane, alveolar fluid clearance, and lung inflammation. Mechanical ventilation parameters were also collected throughout the experiment. Although this model induced a marked decrease in arterial oxygenation with altered alveolar-capillary permeability, it is reproducible and is characterized by a rapid onset, good stability over time, and no fatal complications.
We have developed a piglet model of acid aspiration that reproduces most of the physiological, biological, and pathological features of clinical ARDS, and it will be helpful to further our understanding of the potential lung-protective effects of halogenated agents delivered through devices used for inhaled ICU sedation.

We describe a model of hydrochloric acid-induced acute respiratory distress syndrome (ARDS) in piglets receiving sedation with halogenated agents, isoflurane and sevoflurane, through a device used for inhaled intensive care sedation. This model can be used to investigate the biological mechanisms of halogenated agents on lung injury and repair.

Acute respiratory distress syndrome (ARDS) is a common cause of hypoxemic respiratory failure and death in critically ill patients, and there is an urgent ...

A Reproducible Intensive Care Unit-Oriented Endotoxin Model in Rats

Sepsis and septic shock remain the leading cause of death in intensive care units. Despite significant improvements in sepsis management, mortality still ranges between 20 and 30%. Novel treatment approaches in order to reduce sepsis-related multiorgan failure and death are urgently needed. Robust animal models allow for one or multiple treatment approaches as well as for testing their effect on physiological and molecular parameters. In this article, a simple animal model is presented.
First, general anesthesia is induced in animals either with the use of volatile or by intraperitoneal anesthesia. After placement of an intravenous catheter (tail vein), tracheostomy, and insertion of an intraarterial catheter (tail artery), mechanical ventilation is started. Baseline values of mean arterial blood pressure, arterial blood oxygen saturation, and heart rate are recorded.
The injection of lipopolysaccharides (1 milligram/kilogram body weight) dissolved in phosphate-buffered saline induces a strong and reproducible inflammatory response via the toll-like receptor 4. Fluid corrections as well as the application of norepinephrine are performed based on well-established protocols.
The animal model presented in this article is easy to learn and strongly oriented towards clinical sepsis treatment in an intensive care unit with sedation, mechanical ventilation, continuous blood pressure monitoring, and repetitive blood sampling. Also, the model is reliable, allowing for reproducible data with a limited number of animals in accordance with the 3R (reduce, replace, refine) principles of animal research. While animal experiments in sepsis research cannot easily replaced, repetitive measurements allow for a reduction of animals and keeping septic animals anesthetized diminishes suffering.

Here, we present a reproducible intensive care unit-oriented endotoxin model in rats.

Sepsis and septic shock remain the leading cause of death in intensive care units. Despite significant improvements in sepsis management, mortality still ...

Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, reliable, and real-time information on developmental hemodynamics in sick newborns. The comprehensive assessment is based on a multiparametric approach that overcomes the reliability issues of individual measurements, allows for earlier recognition of cardiovascular compromise and promotes enhanced diagnostic precision and timely management. TnECHO-driven research has led to an enhanced understanding of the mechanisms of illness and the development of predictive models to identify at-risk populations. This information may then be used to formulate a diagnostic impression and provide individualized guidance for the selection of cardiovascular therapies. TnECHO is based on the expert consultative model in which a neonatologist, with advanced training in neonatal hemodynamics, performs comprehensive and standardized TnECHO assessments. The distinction from point of care ultrasonography (POCUS), which provides limited and brief one-time assessments, is important. Neonatal hemodynamics training is a 1-year structured program designed to optimize image acquisition, measurement analysis, and hemodynamic knowledge (physiology, pharmacotherapy) to support cardiovascular decision-making. Neonatologists with hemodynamic expertise are trained to recognize deviations from normal anatomy and appropriately refer cases of possible structural abnormalities. We provide an outline of neonatal hemodynamics training, the standardized TnECHO imaging protocol, and an example of representative echo findings in a hemodynamically significant patent ductus arteriosus.

Presented here is a protocol to perform comprehensive neonatal echocardiography by trained neonatologists in the neonatal intensive care unit. The trained individuals provide longitudinal assessments of heart function, systemic and pulmonary hemodynamics in a consultative role. The manuscript also describes the requirements to become a fully trained neonatal hemodynamics specialist.

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, ...

Enema of Traditional Chinese Medicine for Patients with Severe Acute Pancreatitis

Severe acute pancreatitis (SAP) is characterized by high mortality rates, numerous complications, and extreme difficulties in treatment. A traditional Chinese medicine (TCM) enema has been widely utilized in clinical and experimental studies of SAP. It has been demonstrated to have beneficial effects in protecting pancreatic function and delaying disease progression. The procedure of TCM enema is to perfuse the Chinese medicinal liquid of raw rhubarb (Rheum officinale Baill. DaHuang) from the anus into the rectum and colon. Basic steps of the procedure include boiling the herbal solution in advance, using a disposable enema kit to assist patients in taking a left lying position, raising the patient's hip 10 cm, and carefully inserting the enema 30-35 cm into the anus, with a drip speed of 60-80 drops/min. The medicine liquid temperature should be equivalent to the patient's body temperature, typically between 37-39 &#176;C. The end of the enema operation should be slow, and Tui na (massage therapy) should be administered before extubation. The medication liquid should be kept in the rectum for more than 1 h. After issuing an enema, it is essential to observe the patient's feces and abdomen, and to evaluate the remission of abdominal signs and symptoms.

An enema is a type of traditional Chinese medicine (TCM) therapy used to treat severe acute pancreatitis (SAP). The therapy involves instilling a TCM liquid into the rectum and colon through the anus to keep the liquid in the intestine, absorbing through the intestinal mucosa. This study aims to standardize the enema procedure for SAP patients.

Severe acute pancreatitis (SAP) is characterized by high mortality rates, numerous complications, and extreme difficulties in treatment. A traditional ...