Showing papers in "Journal of Intensive Care Medicine in 2013"
TL;DR: The regulation of normal calcium metabolism is described and the various etiologies of hypocalcemia are focused on, including congenital and acquired disorders of parathyroid hormone and vitamin D, which are encountered in the neonatal, pediatric, and adult critical care settings.
Abstract: Hypocalcemia is common in the critically ill patient. In this population, however, the diagnosis of hypocalcemia is complicated by limitations in the interpretation of the total plasma calcium concentration. These limitations are principally the result of the effects of hypoalbuminemia and disorders of acid-base balance on the total calcium concentration. Thus, measurement of ionized calcium can be critical in determining an individual's true serum calcium status. In this review, we first describe the regulation of normal calcium metabolism and then focus on the various etiologies of hypocalcemia, including congenital and acquired disorders of parathyroid hormone and vitamin D, which are encountered in the neonatal, pediatric, and adult critical care settings. The approach to the treatment of hypocalcemia and the current consensus on treatment of hypocalcemia in the critically ill patient is also presented.
131 citations
TL;DR: The RDW fared better than either Acute Physiologic and Chronic Health Evaluation II or SOFA, and the sum of RDW and APACHE II was a stronger predictor of mortality than either one alone.
Abstract: Introduction: Red cell distribution width (RDW) is reflective of systemic inflammation. The objective of this study was to investigate the association between RDW (on day 1 of development of septic shock) and mortality. Methods: A total of 279 patients with septic shock were included. We categorized the patients into quintiles based on RDW as follows: 19.4%. Results: Red cell distribution width was a strong predictor of hospital mortality with a significant risk gradient across RDW quintiles after multivariable adjustment: RDW 13.5% to 15.5% (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.0-23.4; P = .06); RDW 15.6% to 17.5% (OR, 8.0; 95% CI, 1.5-41.6; P = .01); RDW 17.6% to 19.4% (OR, 25.3; 95% CI, 4.3-149.2; P 19.4% (OR, 12.3; 95% CI, 2.1-73.3; P = .006), all relative to patients with RDW <13.5%. Similar significant robust associations were present for intensive care unit mortality. Estimating the receiver–operating c...
112 citations
TL;DR: The malignant obesity hypoventilation syndrome (MOHS) is a serious multisystem disorder with a high mortality that appears to be relatively common, frequently misdiagnosed, and inadequately treated.
Abstract: Background:The incidence of obesity in westernized nations is increasing at an alarming rate. We have noted an increasing number of patients admitted to our intensive care unit (ICU) with hypercapn...
101 citations
TL;DR: The discussion will focus on primary and secondary mechanisms of injury, spine stabilization and immobilization, surgery, intensive care management, airway and respiratory management, cardiovascular complication management, venous thromboembolism, nutrition and glucose control, infection management, pressure ulcers and early rehabilitation, pharmacologic cord protection, and evolving treatment options including the use of pluripotent stem cells and hypothermia.
Abstract: Approximately 11 000 people suffer traumatic spinal cord injury (TSCI) in the United States, each year. TSCI incidences vary from 13.1 to 52.2 per million people and the mortality rates ranged from 3.1 to 17.5 per million people. This review examines the critical care of TSCI. The discussion will focus on primary and secondary mechanisms of injury, spine stabilization and immobilization, surgery, intensive care management, airway and respiratory management, cardiovascular complication management, venous thromboembolism, nutrition and glucose control, infection management, pressure ulcers and early rehabilitation, pharmacologic cord protection, and evolving treatment options including the use of pluripotent stem cells and hypothermia.
77 citations
TL;DR: Twelve patients with 3,4-methylenedioxymethamphetamine toxicity from a single rave event presented to multiple San Francisco Bay area hospitals with various life-threatening complications including seizures and hyperthermia, contributing to the morbidity and mortality in this case series.
Abstract: Twelve patients with 3,4-methylenedioxymethamphetamine (MDMA) toxicity from a single rave event presented to multiple San Francisco Bay area hospitals with various life-threatening complications including seizures and hyperthermia. Eight required emergent endotracheal intubation and six had hypotension. Hyperkalemia, acute kidney injury, and rhabdomyolysis were present in most of the patients. In all, 2 patients died, 4 survived with permanent neurologic, musculoskeletal, and/or renal sequelae, and 6 survived without any apparent lasting deficits. Hyperthermia was present in 10 patients and was severe (40.9-43° C) in 7. Using multiple cooling methods, the average time to achieve cooling was 2.7 hours. Serum drug analysis was performed on 3 patients, demonstrating toxic MDMA concentrations without the presence of other xenobiotics. Two capsules confiscated by police at the event contained 82% and 98% MDMA, respectively, without other pharmacologically active compounds. Capsule #2 contained 270 mg MDMA, which is more than twice the amount of MDMA usually contained in 1 dose. The MDMA-induced hyperthermia significantly contributed to the morbidity and mortality in this case series. Factors contributing to the severity of the hyperthermia include ingestion of large doses of MDMA, a warm ambient environment, and physical exertion.
66 citations
TL;DR: The literature regarding the use of etomidate and ketamine for RSI in critically ill patients is reviewed and options for sedation during endotracheal intubation in this population are discussed.
Abstract: Given their relative hemodynamic stability, ketamine and etomidate are commonly chosen anesthetic agents for sedation during the endotracheal intubation of critically ill patients. As the use of etomidate has come into question particularly in patients with sepsis, due to its effect of adrenal suppression, there has been a shift in practice with more reliance on ketamine. However, as ketamine relies on a secondary sympathomimetic effect for its cardiovascular stability, cardiovascular and hemodynamic compromise may occur in patients who are catecholamine depleted. We present 2 critically ill patients who experienced cardiac arrest following the administration of ketamine for rapid sequence intubation (RSI). The literature regarding the use of etomidate and ketamine for RSI in critically ill patients is reviewed and options for sedation during endotracheal intubation in this population are discussed.
63 citations
TL;DR: Patients with severe sepsis and septic shock receiving the RB in community and tertiary hospitals experience similar and significant reductions in mortality and hospital length of stay.
Abstract: Background: Improved outcomes for severe sepsis and septic shock have been consistently observed with implementation of early best practice intervention strategies or the 6-hour resuscitation bundle (RB) in single-center studies. This multicenter study examines the in-hospital mortality effect of GENeralized Early Sepsis Intervention Strategies (GENESIS) when utilized in commu- nity and tertiary care settings. Methods: This study was comprised of 2 strategies to assess treatment. The first was a prospective before-and-after observational comparison of historical controls to patients receiving the RB after implementation of GENESIS in 4 community and 4 tertiary hospitals. The second was a concurrent examination comparing patients not achieving all components of the RB to those achieving all components of the RB in 1 community and 2 tertiary care hospitals after implementation of GEN- ESIS. These 4 subgroups merged to comprise a control (historical controls treated before GENESIS and RB not achieved after GENESIS) group and treatment (patients treated after GENESIS and RB achieved after GENESIS) group for comparison. Results: The control group comprised 1554 patients not receiving the RB (952 before GENESIS and 602 RB not achieved after GENESIS). The treatment group comprised 4801 patients receiving the RB (4109 after GENESIS and 692 RB achieved after GENESIS). Patients receiving the RB (treatment group) experienced an in-hospital mortality reduction of 14% (42.8%-28.8%, P < .001) and a 5.1 day decrease in hospital length of stay (20.7 vs 15.6, P < .001) compared to those not receiving the RB (control group). Similar mortality reductions were seen in the before-and-after (43% vs 29%, P < .001) or concurrent RB not achieved versus achieved (42.5% vs 27.2%, P < .001) subgroup comparisons. Conclusions: Patients with severe sepsis and septic shock receiving the RB in community and tertiary hospitals experience similar and significant reductions in mortality and hospital length of stay. These find- ings remained consistent when examined in both before-and-after and concurrent analyses. Early sepsis intervention strategies are associated with 1 life being saved for every 7 treated.
62 citations
TL;DR: Mechanical ventilation, tube feeding, dysphagia, and tracheostomy are exposures associated with increased risk of the development of pneumonia in patients with sICH, and pneumonia shows a significant effect on the morbidity, length of stay, and mortality rate of the patients.
Abstract: Objectives.Pneumonia is an important complication of spontaneous intracerebral hemorrhage (sICH). The purpose of this study was to determine the predictors and outcomes of the development of pneumonia in patients with sICH.Methods.In total, 290 consecutive patients with sICH admitted within 24 hours of stroke onset were investigated in a single center, retrospective study from January 2006 to July 2009. Clinical, biochemical, and imaging variables were registered. Stroke severity and functional outcomes were evaluated with the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS). Baseline variables that predicted pneumonia were investigated and outcomes were assessed.Results.The association of our primary exposure variables, such as mechanical ventilation, tube feeding, dysphagia, and tracheostomy, with pneumonia was highly significant (P < .0001, for each variable). For mechanical ventilation, we observed an odds ratio (OR; 95% confidence interval [CI]) of 9.42 (4.24-20.9); for tube feeding, OR = 22....
49 citations
TL;DR: The evidence for the use of mannitol and hypertonic saline in a variety of disease states causing cerebral edema is summarized, as well as outlining monitoring and safety considerations.
Abstract: Osmotic agents play a vital role in the reduction of elevated intracranial pressure and treatment of cerebral edema in Neurologic critical care. Both mannitol and hypertonic saline reduce cerebral edema in many clinical syndromes, yet there is controversy over agent selection, timing, and dosing regimens. Despite the lack of randomized, controlled trials, our knowledge base on the appropriate clinical use of osmotic agents continues to expand. This review will summarize the evidence for the use of mannitol and hypertonic saline in a variety of disease states causing cerebral edema, as well as outlining monitoring and safety considerations.
42 citations
TL;DR: This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of septicaemia, severe sepsi, and septic shock in the surgical patients.
Abstract: Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.
39 citations
TL;DR: A concise overview of selected extracorporeal modalities currently in clinical use and briefly introduce some new promising techniques for sepsis are provided.
Abstract: The treatment of sepsis is an ongoing challenge for clinicians; despite the wide choice of effective antibiotics to treat infection, sepsis remains the leading cause of morbidity and mortality for patients admitted to an intensive care unit. Dysregulation of the immune response is now recognized to be a key factor in multiple organ dysfunction, yet our therapy for inflammation remains ineffective. It has been advocated for more than a decade that cytokine reduction in blood compartment could lead to a reduction in mortality in sepsis. Over the years, multiple extracorporeal techniques have evolved, with the intent of influencing the circulating levels of inflammatory mediators like cytokines and chemokines, the complement system, as well as factors of the coagulation system. These include high-volume hemofiltration, use of high cutoff membranes, and systems based on adsorption, such as coupled plasma filtration adsorption and the polymyxin-B column. In addition, new experimental systems that utilize human phagocytic cells and immobilized antibodies for targeted immunomodulation have emerged. In the context of limited resources and growing expansion in the availability of technologies, a better understanding of these therapies is required before they can be properly integrated into standard clinical practice in the hope of influencing major clinical outcomes. In this article, we will provide a concise overview of selected extracorporeal modalities currently in clinical use and briefly introduce some new promising techniques for sepsis.
TL;DR: The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.
Abstract: Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.
TL;DR: Monitoring of plasma sodium levels is essential to ensure appropriate response and to adjust the rate of fluid replacement to prevent the risk of cerebral edema from rapid correction of chronic hypernatremia.
Abstract: Hypernatremia, defined as plasma sodium concentration >145 mEq/L, is frequently encountered in critically ill patients admitted to the intensive care unit (ICU). Hypernatremia indicates a decrease in total body water relative to sodium and is invariably associated with plasma hyperosmolality though total body sodium content may be normal, decreased, or increased. Hypernatremia usually occurs as a result of impaired thirst or access to water, with or without increased water losses from renal and extrarenal sources. Critically ill patients in ICU are at high risk of hypernatremia because of their inability to control free water intake as a result of sedation, intubation, change in mental status, and fluid restriction for various other reasons. In addition, excessive fluid losses from various renal or nonrenal sources and treatment with sodium containing fluids are commonly encountered in this population, predisposing them to hypernatremia. The consequences of hypernatremia result from osmotic movement of water across the cell membrane, leading to primarily intracellular and variable degree of extracellular volume depletion. The clinical features depend on severity and rapidity of hypernatremia development with abnormal cognitive and neuromuscular function in many cases and potential risk of hemorrhagic complications or death from vascular stretching and rupture in advanced cases. The management of hypernatremia focuses on judicious replacement of free water deficit to restore normal plasma osmolality as well as identification and correction of underlying causes of hypernatremia. Electrolyte-free water replacement is the preferred therapy though electrolyte (sodium) containing hypotonic fluids can also be used in some circumstances. Oral free water replacement guided by thirst is ideal though parenteral fluid replacement is usually necessary in critically ill ICU patients. Various calculations for estimating free water deficit are available and any can be used to guide initial fluid replacement therapy. Rate of correction depends on rapidity of hypernatremia development, though frequent monitoring of plasma sodium levels is essential to ensure appropriate response and to adjust the rate of fluid replacement to prevent the risk of cerebral edema from rapid correction of chronic hypernatremia. Free water requirements should be routinely assessed in ICU patients and judicious electrolyte and free water replacement prescribed for those at risk of hypernatremia.
TL;DR: Study in mechanically ventilated patients suggest that pleural fluid drainage can result in improved oxygenation for up to 48 hours, but data on clinical outcomes are limited, and further research is needed to determine the effects of pleural fluids drainage on clinical outcome.
Abstract: Pleural effusions are common in critically ill patients. Most effusions in intensive care unit (ICU) patients are of limited clinical significance; however, some are important and require aggressive management. Transudative effusions in the ICU are commonly caused by volume overload, decreased plasma oncotic pressure, and regions of altered pleural pressure attributable to atelectasis and mechanical ventilation. Exudates are sequelae of pulmonary or pleural infection, pulmonary embolism, postsurgical complications, and malignancy. Increases in pleural fluid volume are accommodated principally by chest wall expansion and, to a lesser degree, by lung collapse. Studies in mechanically ventilated patients suggest that pleural fluid drainage can result in improved oxygenation for up to 48 hours, but data on clinical outcomes are limited. Mechanically ventilated patients with pleural effusions should be semirecumbant and treated with higher levels of positive-end expiratory pressure. Rarely, large effusions can cause cardiac tamponade or tension physiology, requiring urgent drainage. Bedside ultrasound is both sensitive and specific for diagnosing pleural effusions in mechanically ventilated patients. Sonographic findings of septation and homogenous echogenicity may suggest an exudative effusion, but definitive diagnosis requires pleural fluid sampling. Thoracentesis should be carried out under ultrasound guidance. Antibiotic regimens for parapneumonic effusions should be based on current pneumonia guidelines, and anaerobic coverage should be included in the case of empyema. Decompression of the pleural space may be necessary to improve respiratory mechanics, as well as to treat complicated effusions. While small-bore catheters inserted under ultrasound guidance may be used for nonseptated effusions, surgical consultation should be sought in cases where this approach fails, or where the effusion appears complex and septated at the outset. Further research is needed to determine the effects of pleural fluid drainage on clinical outcomes in mechanically ventilated patients, to evaluate weaning strategies that include pleural fluid drainage, and to better identify patients in whom pleural effusions are more likely to be infected.
TL;DR: An overview of pregnancy physiology that is relevant to cardiac resuscitation is discussed, the challenges in the various resuscitative steps including a synopsis on perimortem delivery are detailed, and obstetric and nonobstetric causes of mortality and cardiac arrest in pregnancy are described.
Abstract: Cardiac arrest is a rare occurrence in pregnancy and may be related to obstetric or medical causes. Pregnancy is associated with profound physiologic changes that prepare the gravida for the challenges of labor and delivery, and resuscitation of the pregnant patient needs to take these changes into consideration. Cardiac output and plasma volume increase in pregnancy and distribute differently with the uterine circulation receiving approximately 17% of the total cardiac output. On the other hand, cardiac output is sensitive to positional changes in the second half of pregnancy but may improve with a lateral tilt of the gravida. Both oxygen reserve and upper airway size decrease in pregnancy, leading to difficulties surrounding airway management. Changes in the volume of distribution, renal and hepatic clearance may impact drug effects and need to be recognized. This review will discuss an overview of pregnancy physiology that is relevant to cardiac resuscitation, detail the challenges in the various resus...
TL;DR: Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors reinforce holistic approaches to pain management in the ICU.
Abstract: Pain is abundant in the intensive care unit (ICU). Successful analgesia demands a comprehensive appreciation for the etiologies of pain, vigilant clinical assessment, and personalized treatments. For the critically ill, frequent threats to mental and bodily integrity magnify the experience of pain, challenging clinicians to respond swiftly and thoughtfully. Because pain is difficult to predict and physiologic correlates are not specific, self-report remains the gold standard assessment. When communication is limited by intubation or cognitive deficits, behavioral pain scales prove useful. Patient-tailored analgesia aspires to mitigate suffering while optimizing alertness and cognitive capacity. Mindfulness of the neuropsychiatric features of pain helps the ICU clinician to clarify limits of traditional analgesia and identify alternative approaches to care. Armed with empirical data and clinical practice recommendations to better conceptualize, identify, and treat pain and its neuropsychiatric comorbidities, the authors (psychiatric consultants, by trade) reinforce holistic approaches to pain management in the ICU. After all, without attempts to understand and relieve suffering on all fronts, pain will remain undertreated.
TL;DR: The ICU management of aneurysmal subarachnoid hemorrhage can be particularly challenging and requires an awareness of all potential neurologic and medical complications and their urgent treatments, as well as detailed treatment strategies and areas of current and future research.
Abstract: Introduction. Aneurysmal subarachnoid hemorrhage (SAH) has very high morbidity and mortality rates. Optimal intensive care unit (ICU) management requires knowledge of the potential complications that occur in this patient population. Methods. Review of the ICU management of SAH. Level of evidence for specific recommendations is provided. Results. Grading scales utilizing clinical factors and brain imaging studies can help in determining prognosis and are reviewed. Misdiagnosis of SAH is fairly common so the clinical symptoms and signs of SAH are summarized. The ICU management of SAH is discussed beginning with a focus on avoiding aneurysm re-rupture and securing the aneurysm, followed by a review of the neurologic and medical complications that may occur after the aneurysm is secured. Detailed treatment strategies and areas of current and future research are reviewed. Conclusions. The ICU management of the patient with SAH can be particularly challenging and requires an awareness of all potential neurolog...
TL;DR: Patients requiring 3 or more vasoactive drugs rarely survive in the absence of an intervention aimed at correcting the underlying cause such as revascularization or source control surgery.
Abstract: Introduction:Vasoactive drugs are routinely used in critically ill patients with shock to optimize the hemodynamic state while evaluating and treating potentially reversible causes. Limited data exist on the use of multiple vasoactive drugs in the intensive care unit. We hypothesize that the use of 3 or more vasoactive drugs is associated with worse outcomes.Methods:We retrospectively examined the outcome in patients, at least 18 years of age, in whom 3 or more vasoactive drugs were administered simultaneously. We included patients admitted between November 2007 and August 2009. Vasoactive drugs included dopamine, dobutamine, epinephrine, norepinephrine, phenylephrine, and vasopressin. The primary end point was survival to hospital discharge.Results:Sixty-six patients received 3 or more vasoactive drugs simultaneously. Nine patients (14%) survived to ICU discharge and 6 patients (9%) survived to hospital discharge. There was a significant difference in mean Simplified Acute Physiology Score II between sur...
TL;DR: Evaluation for the cause of thrombocytopenia is a common laboratory finding in critically ill patients admitted to the intensive care unit, and the clinician must also guard against spontaneous bleeding due to thromBocy topenia, prophylax against bleeding resulting from an invasive procedure performed in the setting of thROMbocy Topenia.
Abstract: Thrombocytopenia is a common laboratory finding in critically ill patients admitted to the intensive care unit. Potential etiologies of thrombocytopenia are myriad, ranging from acute disease processes and concomitant conditions to exposures and drugs. The mechanism of decreased platelet counts can also be varied: laboratory measurement may be spurious, platelet production may be decreased, or platelet destruction or sequestration may be increased. In addition to evaluation for the cause of thrombocytopenia, the clinician must also guard against spontaneous bleeding due to thrombocytopenia, prophylax against bleeding resulting from an invasive procedure performed in the setting of thrombocytopenia, and treat active bleeding related to thrombocytopenia.
TL;DR: The weaning index is a simple and reproducible parameter that integrates breathing pattern, compliance, inspiratory muscle strength, and ventilatory demand and is the most accurate predictor of weaning success.
Abstract: Background. The quest to obtain an accurate way to predict success when weaning a patient from mechanical ventilation continues. The established parameters such as tidal volume (Vt), respiratory rate (f), negative inspiratory force (NIF), vital capacity (VC), and minute ventilation (V) have not predicted weaning accurately. The frequency-to-tidal volume ratio (f/Vt), or rapid shallow breathing index (RSBI) is a good predictor of weaning success if the value is low, but not when the value approximates 105. Because of the aforementioned, we decided to add 2 corrective factors to the RSBI. The first one was elastance index (EI = peak pressure/NIF) and the second one, the ventilatory demand index (VDI = minute ventilation/10). The result of the product of the RSBI × EI × VDI was called the weaning index (WI). Methods. In order to assess the discriminatory power of WI, we obtained weaning parameters and calculated WI for 59 patients in our intensive care unit and extubated them if RSBI was ≤105. Sensitivity, s...
TL;DR: A 35-year-old woman with a missed ruptured SAA who after an emergent cesarean section went into profound shock and was unable to be resuscitated illustrates the importance of considering the diagnosis of SAA rupture in hemodynamically unstable peripartum females.
Abstract: Splenic artery aneurysm (SAA) is the most common (60%) of all visceral artery aneurysms. The majority of these cases are asymptomatic, but the presentation of their rupture can vary from abdominal/chest pain to cardiovascular collapse (Sadat U, Dar O, Walsh S, Varty K. Splenic artery aneurysms in pregnancy-a systematic review. Int J Surg. 2008;6(3):261-265.). Although rare, the mortality associated with the rupture is as high as 25% (De Vries JE, Schattenkerk ME, Malt RA. Complications of splenic artery aneurysm other than intraperitoneal rupture. Surgery. 1982;91(2):200-204; Caillouette JC, Merchant EB: Ruptured splenic artery aneurysm in pregnancy. Twelfth reported case with maternal and fetal survival. Am J Obstet Gynecol 1993;168(6 Pt 1):1810-1811) and increases to 75% among pregnant women with a concomitant fetal mortality of 95% (O'Grady JP, Day EJ, Toole AL, et al. Splenic artery aneurysm rupture in pregnancy. A review and case report. Obstet Gynecol. 1977; 50(5):627-630). Because of such high maternal and fetal mortality prompt management of SAAs is of utmost importance. We are presenting a case of a 35-year-old woman with a missed ruptured SAA who after an emergent cesarean section went into profound shock and was unable to be resuscitated. This case illustrates the importance of considering the diagnosis of SAA rupture in hemodynamically unstable peripartum females.
TL;DR: The new protocols helped guide practical changes in care that resulted in a 32% decrease in LOS for elderly trauma patients which exceeds the 25% decrease found in other studies.
Abstract: The elderly individuals are the most rapidly growing cohort within the US population, and a corresponding increase is being seen in elderly trauma patients. Elderly patients are more likely to have a hospital length of stay (LOS) in excess of 10 days. They account for 60% of total ICU days. Length of stay is frequently used as a proxy measure for improvement in injury outcomes, changes in quality of care, and hospital outcomes. Patient care protocols are typically created from evidence-based guidelines that serve to reduce variation in care from patient to patient. Patient care protocols have been found to positively impact patient care with reduced duration of mechanical ventilation, shorter LOS in the ICU and shorter overall hospitalization time, reduced mortality, and reduced health care costs. The following study was designed to assess the impact of the implementation of 4 patient care protocols within an elderly trauma population. We hypothesized that the implementation of these protocols would have ...
TL;DR: The use of video laryngoscopy to evaluate the airway of critically ill, mechanically ventilated patients, as a means to reduce the risk of immediate postextubation stridor by assessing the degree of laryngeal edema is reported.
Abstract: Video laryngoscopy has demonstrated utility in airway management. For the present case series, we report the use of video laryngoscopy to evaluate the airway of critically ill, mechanically ventilated patients, as a means to reduce the risk of immediate postextubation stridor by assessing the degree of laryngeal edema. We also describe the use of cellular phone cameras to document and communicate airway edema in using video laryngoscopy for the patients’ medical records. We found video laryngoscopy to be an effective method of assessing airway edema, and cellular phone cameras were useful for recording and documenting video laryngoscopy images for patients’ medical records.
TL;DR: Post-MI cardiogenic shock most commonly occurs as a consequence of severe left ventricular dysfunction, but right ventricular (RV) MI must also be considered, and mortality remains high.
Abstract: Cardiogenic shock is often a devastating consequence of acute myocardial infarction (MI) and portends to significant mortality and morbidity. Despite improvements in expediting the time to treatment and enhancements in available medical therapy and reperfusion techniques, cardiogenic shock remains the most common cause of mortality following MI. Post-MI cardiogenic shock most commonly occurs as a consequence of severe left ventricular dysfunction. Right ventricular (RV) MI must also be considered. Mechanical complications including acute mitral regurgitation, ventricular septal rupture, and ventricular free-wall rupture can also lead to cardiogenic shock. Rapid diagnosis of cardiogenic shock and its underlying cause is pivotal to delivering definitive therapy. Intravenous vasoactive agents and mechanical support devices may temporize the patient's hemodynamic status until definitive therapy by percutaneous or surgical intervention can be performed. Despite prompt management, post-MI cardiogenic shock mortality remains high.
TL;DR: Despite the implementation of a DA-SBT protocol that was individualized to clinician preferences and institutional resources and accompanied by substantial education and reminders for use, compliance to the DA component of this protocol was low and duration of MV remained unchanged.
Abstract: Introduction:While one controlled trial found that a daily awakening and spontaneous breathing trial (DA-SBT) decreases time on mechanical ventilation (MV), there is a paucity of real-world data surrounding the development, implementation, and impact of DA-SBT protocols. We describe a multidisciplinary process improvement effort in 2, 10-bed medical intensive care units (MICUs) at a 330-bed academic medical center that focused on the development, implementation, and evaluation of a new DA-SBT protocol.Methods:A DA-SBT protocol, developed using results from a nursing survey literature and available institutional resources, was implemented after extensive clinician education and institution of quality reminders to boost use. Postprotocol compliance was evaluated. Use of sedation, DA and SBT practices, and clinical outcomes were retrospectively compared between the before and after DA-SBT protocol groups (ie, consecutive MICU patients requiring a continuously infused sedative [CIS] ≥24 hours).Results:In the...
TL;DR: An update on novel advances in Hepatorenal syndrome is provided, with emphasis on the different aspects of management of these patients in the intensive care unit.
Abstract: Hepatorenal syndrome (HRS) is a functional form of acute kidney injury (AKI) associated with advanced liver cirrhosis or fulminant hepatic failure. Various new concepts have emerged since the initial diagnostic criteria and definition of HRS was initially published. These include better understanding of the pathophysiological mechanisms involved in HRS, identification of bacterial infection (especially spontaneous bacterial peritonitis) as the most important HRS-precipitating event, recognition that insufficient cardiac output plays a role in the occurrence of HRS, and evidence that renal failure reverses with pharmacotherapy. Patients with HRS are often critically ill and, by definition, have multiorgan failure. The purpose of this review is to provide an update on novel advances in HRS, with emphasis on the different aspects of management of these patients in the intensive care unit.
TL;DR: Respirable toxicants are a spectrum of irritant and nonirritant gases, vapors, fumes, and airborne particles that can be entrained into the body through the respiratory tract, resulting in exposures that cause pulmonary injury and/or systemic disease.
Abstract: Respirable toxicants are a spectrum of irritant and nonirritant gases, vapors, fumes, and airborne particles that can be entrained into the body through the respiratory tract, resulting in exposures that cause pulmonary injury and/or systemic disease. Sources of respirable toxicants include structural fires, industrial accidents, domestic mishaps, and intentional releases of injurious agents on the battleground (warfare) or in civilian settings (acts of terrorism). Acute toxic inhalational exposures may result in respiratory failure, multisystem organ dysfunction, and death. Management of victims includes assessment and protection of the airway, monitoring and treatment of systemic toxicity, and delivery of exposure-specific and nonspecific therapies that improve outcomes. Treatments may include antidotes, hyperbaric oxygen, and other nonspecific life-supporting interventions.
TL;DR: The challenges of dealing with the “lethal triad” will be discussed, as will the various aspects of damage control and hemostatic resuscitation, and the latest literature and controversy regarding massive transfusions and massive transfusion protocols will be elucidated with inclusion of data from recent military experiences.
Abstract: Definitive management of the exsanguinating patient continues to challenge providers in multiple specialties. Significant hemorrhage may be encountered in a variety of patient care circumstances. Over the past two decades, the vast majority of data and evidence regarding transfusion in the exsanguinating patient has been based upon the trauma literature, and a large amount of recent research has investigated this subject area. In addition to the care of trauma patients, the data which have emerged can also be extrapolated to the treatment of nontrauma patients undergoing transfusion for major hemorrhage. The concept of massive transfusion is an evolving paradigm, and numerous investigations have challenged old principles while creating new controversies. The current review will examine the latest developments in the management of patients with profound hemorrhage. The challenges of dealing with the "lethal triad" will be discussed, as will the various aspects of damage control and hemostatic resuscitation. The latest literature and controversy regarding massive transfusions and massive transfusion protocols will be elucidated with inclusion of data from recent military experiences. Finally, adjuncts including the most recent advances in hemorrhage control, identification of early predictors for massive transfusion, and utilization of pharmacologic and complementary factor agent therapy will be discussed.
TL;DR: This work presents an illustrative case report and review of literature on rhabdomyolysis, a form of systemic inflammatory response syndrome with multiple organ dysfunction that in many ways resembles sepsis.
Abstract: Heatstroke is life-threatening condition characterized by hyperthermia and central nervous system disturbances. It can also be classified as a form of systemic inflammatory response syndrome with multiple organ dysfunction and in many ways resembles sepsis. Like sepsis, most patients with heatstroke demonstrate a hyperdynamic hemodynamic response. In contrast to sepsis, rhabdomyolysis may complicate management and initial fluid resuscitation is not well defined. We present an illustrative case report and review of literature.
TL;DR: The compound 3,4-methylenedioxymethamphetamine (MDMA), more commonly known as "Ecstasy", is a well recognized but often an underappreciated drug of abuse.
Abstract: The compound 3,4-methylenedioxymethamphetamine (MDMA), more commonly known as "Ecstasy", is a well recognized but often an underappreciated drug of abuse. It is a synthetic derivative of amphetamine intended for use as an appetite suppressant when created in 1912. This never materialized and use was dormant until the 1970s, when reports surfaced on its use in psychoanalysis and as a recreational drug. While similar to amphetamine, it has a methylenedioxy ring substitution and resembles the hallucinogen mescaline. Its abuse potential led to its classification as a scheduled I hallucinogen in 1985, by the Food and Drug Administration. It is no longer used for medicinal purposes, except in an investigational setting. Its main effects of mood enhancement and euphoria have made it a favorite in dance clubs and "rave" parties. Reports place it just behind amphetamine compounds and ahead of cocaine in terms of its use in adults, with an estimated consumption of as many as 2 millions tablets weekly and over 28 million worldwide users.... Language: en