Critical Care Physicians Research Articles

Standardized Curriculum Improves Physician and Nurse Confidence and Competence in Brain Death (P12-2.005)

<h3>Objective:</h3> To study the impact of a standardized brain death curriculum on physician and nurse competence, confidence, and comfort. <h3>Background:</h3> There is decreased familiarity with and exposure to brain death amongst medical professionals when compared with cardiac death. Therefore, targeted education should be offered to multidisciplinary healthcare providers to impact competence and familiarity with this entity. <h3>Design/Methods:</h3> Brain death educational curricula were developed for and offered to (A) neurosciences and critical care physicians to effect accurate declaration and discussion of brain death, and (B) critical care nursing to improve confidence and competence in answering family questions about brain death at the bedside. Trainees and attending physicians underwent a formal didactic followed by simulation-based training incorporating examination and communication skills. Critical care nurses underwent formalized didactic followed by peer-based simulated conversations of frequently asked questions. All participants submitted pre-curriculum and post-curriculum surveys that included a combination of Likert, fill-in, and multiple-choice questions as well as a knowledge test. Wilcoxon signed-rank test and Kruskal-Wallis test were used for statistical analysis (P&lt;0.05). <h3>Results:</h3> 46 neurosciences and critical care physicians and 21 critical care nurses participated in their respective brain death curriculum. Mean scores on knowledge test improved from 5.3 to 6.9 out of 10 for physicians (p&lt;0.001) and from 4.2 to 6.2 out of 8 for nurses (p&lt;0.001). Mean physician confidence in performing independent brain death declaration increased from 3.6 to 7.7, out of 10 (p&lt;0.001). Mean physician comfort documenting a brain death assessment increased from 3.7 to 7.9, out of 10 (p&lt;0.001). Mean comfort in discussing brain death with patients’ family increased from 5.0 to 8.1 for physicians and from 5.3 to 7.8 for nurses (both out of 10, both p&lt;0.001). <h3>Conclusions:</h3> Formalized education on brain death improves confidence, comfort, and competence in brain death among physicians and nurses. <b>Disclosure:</b> Dr. Hodosevich has nothing to disclose. Dr. LaBuzetta has nothing to disclose.

Women as a Growing Force in Critical Care Medicine-the Journal, Profession, and Society.

Women as a Growing Force in Critical Care Medicine-the Journal, Profession, and Society.

Abdominal Organ Transplantation: Noteworthy Literature in 2022.

This review highlights noteworthy literature published in 2022 pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We begin by exploring the impacts that the COVID-19 pandemic has had across the field of abdominal organ transplantation, including the successful use of grafts procured from COVID-19-infected donors. In pancreatic transplantation, we highlight several studies on dexmedetomidine and ischemia-reperfusion injury, equity in transplantation, and medical management, as well as studies comparing pancreatic transplantation to islet cell transplantation. In our section on intestinal transplantation, we explore donor selection. Kidney transplantation topics include cardiovascular risk management, obesity, and intraoperative management, including fluid resuscitation, dexmedetomidine, and sugammadex. The liver transplantation section focuses on clinical trials, systematic reviews, and meta-analyses published in 2022 and covers a wide range of topics, including machine perfusion, cardiovascular issues, renal issues, and coagulation/transfusion.

Losing Ceci

In this narrative medicine essay, a critical care physician’s shared grief with a father who also recently experienced the death of a young child helps guide him back from his family’s unimaginable loss.

Made With Love in a Petri Dish

In this narrative medicine essay, a pediatric critical care physician imagines the future discussion with her son about his conception and birth and recounts how she and her husband decided on expanding their family via gestational surrogacy.

Does Practice Match Training? Consultation Practices in Surgical Critical Care

IntroductionIntensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation. MethodsWe surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried. Results314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015). ConclusionsICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents’ scope of practice closely matched their training.

Satisfaction, Stress, and Turnover: Comparing U.S. Intensivist Physicians Before and During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic.

A cross-sectional electronic survey. Critical care practices in the United States. U.S. physician members of the Society for Critical Care Medicine. A total of 1,148 intensivists completed online surveys administered in two waves: in 2016 (693 respondents) and in the late 2021 to early 2022 (455 respondents). They reported demographic and practice characteristics, self-perceived levels of satisfaction, stress, health, and intention to leave their current job. U.S.-based critical care physicians in 2022 report significantly lower levels of job satisfaction compared with 2016. Frequency of work stress and turnover intention also increased, whereas WLB satisfaction has remained the same. Nearly two-thirds of intensivists wish they could work fewer hours, and this discontentment is correlated with decreased satisfaction, increased stress, and increased turnover, particularly in pandemic respondents. More than 25% of physicians rated their mental health as poor or fair, and 20% rated their physical health as poor or fair; these self-ratings correlated with decreased satisfaction and increased stress and turnover intention. The SARS-CoV-2 pandemic has further burdened an already-strained critical care workforce. During the pandemic, job satisfaction fell, work stress became more frequent, and turnover intention increased for critical care physicians. They also have consistently low rates of WLB satisfaction. Work hours matter the most for physician satisfaction, stress, and turnover intention, and the desire to work fewer hours is negatively related to all outcomes. Many critical care physicians reported poor mental and physical health during the pandemic, which is strongly and negatively related to all outcomes. These results emphasize the importance of prioritizing the working preferences and the self-care of intensivist physicians.

Moral Orientation, Moral Decision-Making, and Moral Distress Among Critical Care Physicians: A Qualitative Study.

To explore when and how critical care physicians experience moral distress in the workplace and its consequences, how physicians' professional interactions with colleagues affected their perceived level of moral distress, and in which circumstances professional rewards were experienced and mitigated moral distress. Interview-based qualitative study using inductive thematic analysis. Twenty critical care physicians practicing in Canadian ICUs who expressed interest in participating in a semi-structured interview after completion of a national, cross-sectional survey of moral distress in ICU physicians. Study participants described different ways to perceive and resolve morally challenging clinical situations, which were grouped into four clinical moral orientations: virtuous, resigned, deferring, and empathic. Moral orientations resulted from unique combinations of strength of personal moral beliefs and perceived power over moral clinical decision-making, which led to different rationales for moral decision-making. Study findings illustrate how sociocultural, legal, and clinical contexts influenced individual physicians' moral orientation and how moral orientation altered perceived moral distress and moral satisfaction. The degree of dissonance between individual moral orientations within care team determined, in part, the quantity of "negative judgments" and/or "social support" that physicians obtained from their colleagues. The levels of moral distress, moral satisfaction, social judgment, and social support ultimately affected the type and severity of the negative consequences experienced by ICU physicians. An expanded understanding of moral orientations provides an additional tool to address the problem of moral distress in the critical care setting. Diversity in moral orientations may explain, in part, the variability in moral distress levels among clinicians and likely contributes to interpersonal conflicts in the ICU setting. Additional investigations on different moral orientations in various clinical environments are much needed to inform the design of effective systemic and institutional interventions that address healthcare professionals' moral distress and mitigate its negative consequences.

Acute Kidney Injury and Renal Replacement Therapy: A Review and Update for the Perioperative Physician.

Post-operative acute kidney injury is a devastating complication with significant morbidity and mortality associated with it. The perioperative anesthesiologist is in a unique position to potentially mitigate the risk of postoperative AKI, however, understanding the pathophysiology, risk factors and preventative strategies is paramount. There are also certain clinical scenarios, where renal replacement therapy may be indicated intraoperatively including severe electrolyte abnormalities, metabolic acidosis and massive volume overload. A multidisciplinary approach including the nephrologist, critical care physician, surgeon and anesthesiologist is necessary to determine the optimal management of these critically ill patients.

Health and Well-Being of Intensive Care Unit Physicians: How to Ensure the Longevity of a Critical Specialty.

A second epidemic of burnout, fatigue, anxiety, and moral distress has emerged concurrently with the coronavirus disease 2019 (COVID-19) pandemic, and critical care physicians are especially affected. This article reviews the history of burnout in health care workers, presents the signs and symptoms, discusses the specific impact of the COVID-19 pandemic on intensive care unit caregivers, and attempts to identify potential strategies to combat the Great Resignation disproportionately affecting health care workers. The article also focuses on how the specialty can amplify the voices and highlight the leadership potential of underrepresented minorities, physicians with disabilities, and the aging physician population.

Perspectives on Antibiotic Stewardship Programs among Health Care Providers at Two University Hospitals in Egypt

The perspectives of healthcare professionals on antibiotic stewardship programs (ASPs) should be explored. Any antibiotic stewardship strategy must be individualized based on patient needs, prescription habits, and local resources. The current study aimed to explore the perspectives of healthcare providers on antibiotics stewardship and their awareness of these perspectives. Furthermore, potential barriers to the application of ASPs should be identified and addressed. This exploratory cross-sectional study utilized a qualitative method to evaluate critical care physicians, pediatricians, and clinical pharmacists (n = 43). The mean age of the physicians was 32 ± 1.5 years. Among them, approximately two-thirds (66%) were women. A thematic content analysis was performed to examine the responses of the participants and to prioritize the recommendations for and barriers to the implementation of ASPs from the perspective of healthcare providers. According to the interviewees, the primary obstacles include lack of time in implementation and monitoring and lack of awareness of the need for ASPs. All respondents recommended the implementation of supervised and continuous trainings. In conclusion, the abovementioned barriers must be adequately addressed to facilitate the implementation of ASPs.

Impact of Tele-Emergency Consultations on Pediatric Interfacility Transfers

Pediatric referral centers are increasingly using telemedicine to provide consultations to help care for acutely ill children presenting to rural and community emergency departments (EDs). These pediatric telemedicine consultations may help improve physician decision-making and may reduce the frequency of overtriage and interfacility transfers. To examine the use of pediatric critical care telemedicine vs telephone consultations associated with risk-adjusted transfer rates of acutely ill children from community and rural EDs. A cluster-randomized crossover trial was conducted between November 18, 2015, and March 26, 2018. Analyses were conducted from January 19, 2018, to July 23, 2022, 2022. Participants included acutely ill children aged 14 years and younger presenting to a participating ED in 15 rural and community EDs in northern California. Participating EDs were randomized to use telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine:1 telephone) crossover treatment assignment sequences. Intention-to-treat, treatment-received, and per-protocol analyses were performed to determine the risk of transfer using mixed effects Poisson regression analyses with random intercepts for presenting EDs to account for hospital-level clustering. A total of 696 children (392 boys [56.3%]; mean [SD] age, 4.2 [4.6] years) were enrolled. Of the 537 children (77.2%) assigned to telemedicine, 251 (46.7%) received the intervention. In the intention-to-treat analysis, patients assigned to the telemedicine arm were less likely to be transferred compared with patients assigned to the telephone arm after adjusting for patient age, severity of illness, and hospital study period (risk rate [RR], 0.93; 95% CI, 0.88-0.99). The adjusted risk of transfer was significantly lower in the telemedicine arm compared with the telephone arm in both the treatment-received analysis (RR, 0.81; 95% CI, 0.71-0.94) and the per-protocol analysis (RR, 0.79; 95% CI, 0.68-0.92). In this randomized trial, the use of telemedicine to conduct consultations for acutely ill children in rural and community EDs resulted in less frequent overall interfacility transfers than consultations done by telephone. ClinicalTrials.gov Identifier: NCT02877810.

COVID-19 pandemic experiences, ethical conflict and decision-making process in critical care professionals (Quali-Ethics-COVID-19 research part 1): An international qualitative study.

The aim of this study was to explore the sources of ethical conflict and the decision-making processes of ICU nurses and physicians during the first and subsequent waves of the COVID-19 pandemic. Depside several studies exploring ethical conflicts during COVID-19 pandemic, few studies have explored in depth the perceptions and experiences of critical care professionals regarding these conflicts, the decision-making process or which have analysed the complexity of actually implementing the recommendations of scientific societies and professional/healthcare institutions in interdisciplinary samples. A descriptive phenomenological study. Thirty-eight in-depth interviews were conducted with critical care nurses and physicians from five hospitals in Spain and Italy between December 2020 and May 2021. A thematic content analysis of the interview transcripts was conducted by two researchers. Consolidated criteria for reporting qualitative research (COREQ) were employed to ensure the quality and transparency of this study. Two main themes emerged as sources of ethical conflict: the approach to end of life in exceptional circumstances and the lack of humanisation and care resources. The former comprised two subthemes: end-of-life care and withholding and withdrawal of life-sustaining treatment; the latter comprised three subthemes: the impossibility of guaranteeing the same opportunities to all, fear of contagion as a barrier to taking decisions and the need to humanise care. Professionals sought to take their decisions in line with professional ethics and bioethical principles, but, nevertheless, they experienced moral dilemmas and moral distress when not being able to care for, or to treat, their patients as they believed fit. Further education and training are recommended on the provision of end-of-life and post-mortem care, effective communication techniques via video calls, disclosure of bad news and bioethical models for decision-making in highly demanding situations of uncertainty, such as those experienced during the COVID-19 pandemic.

PrehospitaL Ultrasound in Undifferentiated DyspnEa (PreLUDE): a prospective, clinical, observational study

BackgroundDiagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy.MethodsProspective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea.ResultsIn total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%–69%) before POCUS compared to 65% (95% CI 53%–75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66–0.78) before POCUS compared to 0.79 (0.73–0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82–0.91) before POCUS and 0.93 (0.88–0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%–94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%–100%).ConclusionSupplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure.Trial registration: Registered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1.

Intensive care management of acute diseases of the aorta

Acute aortic diseases represent agroup of complex severe and often fatal medical conditions. Although they are significantly rarer than cardiac or thromboembolic events, they are an important differential diagnosis to be ruled out, e.g., in the clinical work-up of acute chest pain.Treatment, especially surgical interventions, depends on the progression, extent and size of the pathology and whenever possible should be performed in specialized centers with the appropriate experience.Intensive care monitoring is advisable as arange of peracute complications can occur even in initially stable patients. Depending on the clinical presentation and affected structures, anumber of severe complications need to be anticipated by critical care physicians. Additionally, anotable symptom is severe and refractory hypertension, especially in the acute phase. This article provides asummary of the most frequent clinical pictures and corresponding treatment options. Furthermore, the principles of initial patient stabilization and treatment as well as the perioperative management of complex surgical procedures on the aorta are discussed.

The Story of the Pulmonary Artery Catheter: Five Decades in Critical Care Medicine.

The Story of the Pulmonary Artery Catheter: Five Decades in Critical Care Medicine.

Assessing Barriers to Implementation of Machine Learning and Artificial Intelligence-Based Tools in Critical Care: Web-Based Survey Study.

Although there is considerable interest in machine learning (ML) and artificial intelligence (AI) in critical care, the implementation of effective algorithms into practice has been limited. We sought to understand physician perspectives of a novel intubation prediction tool. Further, we sought to understand health care provider and nonprovider perspectives on the use of ML in health care. We aim to use the data gathered to elucidate implementation barriers and determinants of this intubation prediction tool, as well as ML/AI-based algorithms in critical care and health care in general. We developed 2 anonymous surveys in Qualtrics, 1 single-center survey distributed to 99 critical care physicians via email, and 1 social media survey distributed via Facebook and Twitter with branching logic to tailor questions for providers and nonproviders. The surveys included a mixture of categorical, Likert scale, and free-text items. Likert scale means with SD were reported from 1 to 5. We used student t tests to examine the differences between groups. In addition, Likert scale responses were converted into 3 categories, and percentage values were reported in order to demonstrate the distribution of responses. Qualitative free-text responses were reviewed by a member of the study team to determine validity, and content analysis was performed to determine common themes in responses. Out of 99 critical care physicians, 47 (48%) completed the single-center survey. Perceived knowledge of ML was low with a mean Likert score of 2.4 out of 5 (SD 0.96), with 7.5% of respondents rating their knowledge as a 4 or 5. The willingness to use the ML-based algorithm was 3.32 out of 5 (SD 0.95), with 75% of respondents answering 3 out of 5. The social media survey had 770 total responses with 605 (79%) providers and 165 (21%) nonproviders. We found no difference in providers' perceived knowledge based on level of experience in either survey. We found that nonproviders had significantly less perceived knowledge of ML (mean 3.04 out of 5, SD 1.53 vs mean 3.43, SD 0.941; P<.001) and comfort with ML (mean 3.28 out of 5, SD 1.02 vs mean 3.53, SD 0.935; P=.004) than providers. Free-text responses revealed multiple shared concerns, including accuracy/reliability, data bias, patient safety, and privacy/security risks. These data suggest that providers and nonproviders have positive perceptions of ML-based tools, and that a tool to predict the need for intubation would be of interest to critical care providers. There were many shared concerns about ML/AI in health care elucidated by the surveys. These results provide a baseline evaluation of implementation barriers and determinants of ML/AI-based tools that will be important in their optimal implementation and adoption in the critical care setting and health care in general.

Lessons From COVID-19 for the Next War: Crisis Standards of Care in the Role 3 Intensive Care Unit.

The rationing of medical resources became a common practice during the SARS-CoV-2 (COVID-19) pandemic. To cope with overwhelming patient numbers, hospitals were forced to adopt "crisis standards of care" (CSC) guidelines, which allow physicians to navigate the task of rationing health care resources in both an effective and ethically sound manner. The Military Health System currently has clinical guidelines for mass casualty incident (MCI) triage but lacks deployed Role 3 intensive care unit (ICU) CSC guidelines. In future peer and near-peer conflicts, this gap may prove detrimental when thousands of casualties following a single battle create a continuous and prolonged mass casualty event. The challenges of providing critical care in a battlefield hospital during a large conflict are unique and numerous, but lessons from COVID-19 ICUs such as transitioning to a utilitarian ethic, clear definitions, decision points, and decision authorities, as well as the establishment of clinical practice guidelines formulated from evidence-based protocols, can better prepare the U.S. expeditionary medical force for future conflicts. A battlefield CSC will allow military critical care physicians and nurses to manage overwhelmed ICUs and make better triage decisions, allowing them to provide a higher quality of care to the collective. In this commentary, we explore the need for Wartime CSC in the battlefield Role 3 ICU and the tools and methods used by civilian and military institutions to create and enact CSCs throughout the COVID-19 pandemic.

Mannheim Index versus APACHE II Score as Predictors of Mortality in Abdominal Sepsis in a 4th Level Ecuadorian Hospital

Introduction: In the last 30 years, scoring systems have been developed to determine patients’ illness severity or prognosis. In the present work, the role of the Mannheim Prognostic Index (MPI) to predict the risk of mortality, complications, prolonged hospital-stay, and the need for ICU was determined in all the patients who presented secondary peritonitis, and to validate the test as a useful and an easy tool to apply in the clinical practice of the surgeon and critical care physician. Materials and methods: An observational, retrospective, cross-sectional and analytical study was conducted. Results: The effectiveness of the MPI was compared to another widely used mortality prediction system such as Apache II; 279 patients from the Luis Vernaza were included. The prediction rate was 93.3% and 86.9%, respectively. Conclusions: Although Mannheim presents an excellent response as a predictor of mortality, its assessment is not infallible since other factors remain unconsidered; and these may cause a patient who was assessed as having a low risk of mortality to be deceased.

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?