Objectives:To update the Society of Critical Care Medicine’s guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research.Design:An appointed Task Force followed a standard, systematic, and evidence-

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research.

Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering when “curative” therapies are futile. In the Intensive Care Unit (ICU), critically ill patients receive life-sustaining therapies with the goal of restoring or maintaining organ function. Palliative Care in the ICU is a widely discussed topic and it is increasingly applied in clinics. It encompasses symptoms control and end-of-life management, communication with relatives and setting goals of care ensuring dignity in death and decision-making power. However, effective application of Palliative Care in ICU presupposes specific knowledge and training which anesthesiologists and critical care physicians may lack. Moreover, logistic issues such protocols for patients’ selection, application models and triggers for consultation of external experts are still matter of debate. The aim of this review is to provide the anesthesiologists and intensivists an overview of the aims, current evidence and practical advices about the application of palliative care in ICU.

/pdf/palliative-care-in-intensive-care-units-why-where-what-who-1x17ykyjw7.pdf

Palliative care in intensive care units: why, where, what, who, when, how

Hypertriglyceridemic pancreatitis (HTGP) typically occurs in patients with an underlying dyslipidemia (such as type I, IV or V dyslipidemia) and in the presence of a secondary condition, such as inadequately controlled diabetes, excess alcohol consumption or medication use. Although the symptoms of HTGP are similar to those of acute pancreatitis from other etiologies, HTGP is often associated with greater clinical severity and rate of complications. Therefore, accurate diagnosis of HTGP is essential so that patients receive the appropriate treatment. Novel therapies that aim to reduce the incidence of pancreatitis in this patient population are now available or in development. Understanding the etiology, pathophysiology and clinical characteristics of HTGP will enable future development of therapeutic agents to treat HTGP.

Hypertriglyceridemic pancreatitis: Epidemiology, pathophysiology and clinical management

Tobacco smoke contains a variety of genotoxic carcinogens that form adducts with DNA and protein in the tissues of smokers. Not only are these biochemical events relevant to the carcinogenic process, but the detection of adducts provides a means of monitoring exposure to tobacco smoke. Characterization of smoking-related adducts has shed light on the mechanisms of smoking-related diseases and many different types of smoking-derived DNA and protein adducts have been identified. Such approaches also reveal the potential harm of environmental tobacco smoke (ETS) to nonsmokers, infants and children. Because the majority of tobacco-smoke carcinogens are not exclusive to this source of exposure, studies comparing smokers and nonsmokers may be confounded by other environmental sources. Nevertheless, certain DNA and protein adducts have been validated as biomarkers of exposure to tobacco smoke, with continuing applications in the study of ETS exposures, cancer prevention and tobacco product legislation. Our article is a review of the literature on smoking-related adducts in human tissues published since 2002.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/ijc.27827

DNA and protein adducts in human tissues resulting from exposure to tobacco smoke.

Intensivists are increasingly needed to care for the critically ill and manage ICUs as ICU beds, utilization, acuity of illness, complexity of care and costs continue to rise. However, there is a nationwide shortage of intensivists that has occurred despite years of well publicized warnings of an impending workforce crisis from specialty societies and the federal government. The magnitude of the intensivist shortfall, however, is difficult to determine because there are many perspectives of optimal ICU administration, patient coverage and intensivist availability and a lack of national data on intensivist practices. Nevertheless, the intensivist shortfall is quite real as evidenced by the alternative solutions that hospitals are deploying to provide care for their critically ill patients. In the midst of these manpower struggles, the critical care environment is dynamically changing and becoming more stressful. Severe hospital bed availability and fiscal constraints are forcing ICUs to alter their approaches to triage, throughput and unit staffing. National and local organizations are mandating that hospitals comply with resource intensive and arguably unproven initiatives to monitor and improve patient safety and quality, and informatics systems. Lastly, there is an ongoing sense of professional dissatisfaction among intensivists and a lack of public awareness that critical care medicine is even a distinct specialty. This article offers proposals to increase the adult intensivist workforce through expansion and enhancements of internal medicine based critical care training programs, incentives for recent graduates to enter the critical care medicine field, suggestions for improvements in the critical care profession and workplace to encourage senior intensivists to remain in the field, proactive marketing of critical care, and expanded engagement by the critical care societies in the challenges facing intensivists.

/pdf/critical-care-medicine-in-the-united-states-addressing-the-2rgshid2dl.pdf

Critical care medicine in the United States: addressing the intensivist shortage and image of the specialty.

Gender is a risk factor for lung cancer.

The Leapfrog initiative for intensive care unit physician staffing and its impact on intensive care unit performance: a narrative review.

Cocaine use continues to be a major public health problem in the United States. Although many of the initial signs and symptoms of cocaine intoxication result from increased stimulation of the sympathetic nervous system, this condition can present as a spectrum of acuity from hypertension and tachycardia to multiorgan system failure. Classic features of acute intoxication include tachycardia, arterial vasoconstriction, enhanced thrombus formation, mydriasis, psychomotor agitation, and altered level of consciousness. At the extreme end of this toxidrome is a rare condition known as cocaine-induced agitated delirium. This syndrome is characterized by severe cardiopulmonary dysfunction, hyperthermia, and acute neurologic changes frequently leading to death. We report a case of cocaine-induced agitated delirium in a man who presented to our institution in a paradoxical form of circulatory shock. Rapid evaluation, recognition, and proper management enabled our patient not only to survive but also to leave the hospital without neurologic sequelae.

Cocaine-Induced Agitated Delirium: A Case Report and Review

The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU) are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees) and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.

/pdf/benefits-of-high-intensity-intensive-care-unit-physician-4z2afhz4mi.pdf

Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act

Background:Many terminally ill patients experience an increasing intensity of medical care, an escalation frequently not consistent with their preferences. In 2009, formal palliative care consultation (PCC) was integrated into our medical intensive care unit (ICU). We hypothesized that significant differences in clinical and economic outcomes exist between ICU patients who received PCC and those who did not.Methods:We reviewed ICU admissions between July and October 2010, identified 41 patients who received PCC, and randomly selected 80 patients who did not. We measured clinical outcomes and economic variables associated with patients’ ICU courses.Results:Patients in the PCC group were older (average 64 years, standard deviation [SD] 19.2 vs 55.6 years, SD 14.5; P = .021) and sicker (median Acute Physiology and Chronic Health Evaluation IV score 85.5, interquartile range [IQR] 60.5-107.5 vs 60, IQR 39.2-74.75; P < .001) than the non-PCC controls. PCC patients received significantly more total days of ICU ...

James Gasperino

Papers

Gender is a risk factor for lung cancer.

The Leapfrog initiative for intensive care unit physician staffing and its impact on intensive care unit performance: a narrative review.

Cocaine-Induced Agitated Delirium: A Case Report and Review

Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act

Integrating Palliative Care into Critical Care: A Quality Improvement Study