BACKGROUND: Critically ill patients are susceptible to injury of the intestinal mucosa, changes in gut permeability, and failure of intestinal defense mechanisms. These conditions put the patients at risk for infection and multiple organ dysfunction syndrome. Specific therapies are needed to prevent gut failure during critical illness. OBJECTIVE: The purpose of this literature review is to provide a better understanding of the normal defense mechanisms of the gut and alterations associated with ischemia-reperfusion injury, risk of infection, and the link to multiple organ dysfunction syndrome in critically ill patients. Implications for early enteral stimulation and nutrition are included. METHODS: Medical and nursing studies on the intestinal response to critical illness and on the implications for early enteral nutrition in critically ill patients were reviewed. RESULTS: Significant advances have been made in understanding the normal defense mechanisms of the gut, including barrier and immune functions. Translocation of bacteria, mediators of the inflammatory response, and the microcirculation play a role in the response to critical illness. Enteral nutrition that includes glutamine and arginine enhances gut function and improves patients' outcomes in some clinical states. DISCUSSION: Further research should focus on specific strategies to enhance gut function, prevent loss of gut integrity, and improve patients' outcomes. These strategies include maintaining mesenteric blood flow, using gastric tonometry to assess oxygenation, inhibiting inflammatory mediators, and using growth factors to modify the metabolic state in patients who are critically ill.

BACKGROUND: Although oral hygiene is difficult to perform in orally intubated, critically ill patients, oropharyngeal status may be related to acquisition of nosocomial organisms and should therefore be addressed. OBJECTIVE: To develop a clinical tool for assessment of the mouth in orally intubated patients. METHODS: Sixteen orally intubated patients from one surgical and one medical intensive care unit were subjects. Demographic, clinical, and baseline oropharyngeal assessment data, including sputum and mouth cultures, were obtained on patient admission to the study and every other day. RESULTS: Oropharyngeal cultures of four subjects grew nosocomial bacterial organisms and of two subjects, fungal species. These same organisms were cultured from sputum specimens. Seven patients displayed severe xerostomia; 10 lip lesions were identified in nine subjects, 8 tongue lesions in nine subjects, and 8 mucosal lesions in nine subjects. CONCLUSION: Systemic oropharyngeal assessment in critically ill orally intubated patients may prevent more serious oropharyngeal infections.

OBJECTIVE: To develop a conceptual path model to explain the effects of a set of personal and work-related independent variables and the dependent variables of situational stress, job stress and job motivation on job satisfaction among critical care nurses. DESIGN: A prospective descriptive study using a conceptual path model. SETTING: Nine hospitals licensed for at least 250 beds in the northeastern, northwestern, northcentral, and southern regions of Florida. SAMPLE: Three hundred female critical care nurses employed in the nine hospitals who had worked full-time for at least 3 months. MEASUREMENTS: Subjects were administered a demographic and work survey questionnaire, Daily Hassles Instrument, Psychological Hardiness Test and the Job Diagnostic Inventory. MAIN OUTCOME MEASURES: A conceptual path model was constructed to illustrate the effects of a set of personal and work-related independent variables and the dependent variables of situational stress, job stress and job motivation on job satisfaction. MAIN RESULTS: Path analysis of a job satisfaction model resulted in a causal progression of situational stress leading to either job stress or job motivation, both affecting job satisfaction. The results showed that job stress, job motivation, job expectations, meaningful work, knowledge of work results, commitment to career, health difficulties, task identity, supervision, dealing with others at work, opportunity for advancement, pay and job security had a significant effect on job satisfaction. CONCLUSION: Thirteen variables had a significant effect on job satisfaction and explained 63% of the variance. The four most significant effects on job satisfaction were opportunities for advancement, meaningfulness of work, pay and supervision. Commitment to the career, task identity and job security had a modest effect on job satisfaction.