Critical Care Physicians Research Articles

A multicenter observational study to establish practice for circulatory death declaration for organ donation in South Korea

Background This study aimed to determine the proportion of organ donors suitable for donation after circulatory death and investigate the current process followed by critical care physicians for declaring circulatory death to establish organ donation. Methods This observational study involved potential organ donors who had recently died after discontinuation of life support. We conducted an online survey of intensivists to determine how these deaths were confirmed. Results Among the 177 patients who died after withdrawal of life-sustaining treatment across 19 intensive care units in 11 institutions, 49 (27.7%) were considered potential donors. According to general medical criteria for organ donation, 20 (11.3%) patients were identified as medically suitable donors. Notably, 116 (73.9%) patients exhibited a flat electrocardiogram within 5 min after the loss of pulse. In the survey, 90 physicians (59.2%) agreed to implement the concept of the 5-min no-touch period for the declaration of circulatory death. Conclusions This study found that 11.3% of the patients who died following the withdrawal of life-sustaining treatment in the intensive care units were identified as suitable donors after circulatory death. Most of critical care physicians agree with the concept of a 5-min no-touch period for the declaration of circulatory death.

Extubation Advisor: Implementation and Evaluation of A Novel Extubation Clinical Decision Support Tool.

Extubation Advisor (EA) is a novel software tool that generates a synoptic report for each Spontaneous Breathing Trial (SBT) conducted to inform extubation decision-making. To assess bedside EA implementation, perceptions of utility, and identify barriers and facilitators of use. We conducted a phase I mixed-methods interventional study in three mixed intensive care unit (ICUs) in two academic hospitals. We interviewed critical care physicians (MDs) and respiratory therapists (RTs) regarding user-centered design principles and usability. We evaluated our ability to consent participants (feasibility threshold 50%), capture complete data (threshold 90%), generate and review EA reports in real-time (thresholds 75% and 80%, respectively), and MD perception of tool usefulness (6-point Likert scale). We analyzed interview transcripts using inductive coding to identify facilitators and barriers to EA implementation and perceived benefit of tool use. We enrolled 31 patients who underwent 70 SBTs. Although consent rates [31/31 (100%], complete data capture [68/68 (100%)], and EA report generation [68/70 (97.1%)] exceeded feasibility thresholds, reports were reviewed by MDs for [55/70 (78.6%)] SBTs. Mean MD usefulness score was 4.0/6. Based on feedback obtained from 36 interviews (15 MDs, 21 RTs), we revised the EA report twice and identified facilitators (ability to track patient progress, enhance extubation decision-making, and provide support in resource-limited settings) and barriers (resource constraints, need for education) to tool implementation. Half of respondents (9 MDs, 9 RTs; combined 50%) perceived definite or potential benefit to EA tool use. This is the first study of a waveform-based variability-derived, predictive clinical decision support tool evaluated in adult ICUs. Our findings support the feasibility of integrating the EA tool into bedside workflow. Clinical trials are needed to assess the utility of the EA tool in practice and its impact on extubation decision-making and outcomes. NCT04708509.

Doctors as Device Manufacturers? Regulation of Clinician-Generated Innovation in the ICU.

Critical care physicians are rich sources of innovation, developing new diagnostic, prognostic, and treatment tools they deploy in clinical practice, including novel software-based tools. Many of these tools are validated and promise to actively help patients, but physicians may be unlikely to distribute, implement, or share them with other centers noncommercially because of unsettled ethical, regulatory, or medicolegal concerns. This Viewpoint explores the potential barriers and risks critical care physicians face in disseminating device-related innovations for noncommercial purposes and proposes a framework for risk-based evaluation to foster clear pathways to safeguard equitable patient access and responsible implementation of clinician-generated technological innovations in critical care.

Examining the impact of sleep deprivation on medical reasoning’s performance among anaesthesiology residents and doctors: a prospective study

BackgroundWorking long consecutive hours’ is common for anaesthesia and critical care physicians. It is associated with impaired medical reasoning’s performance of anaesthesiology and serious medical errors. However, no study has yet investigated the impact of working long consecutive hours’ on medical reasoning.ObjectiveThe present study evaluated the impact of working long consecutive hours’ on the medical reasoning’s performance of anaesthesiology and intensive care physicians (residents and seniors).MethodsThis multicentric, prospective, cross-over study was conducted in 5 public hospitals of Normandy region. Two groups of anaesthesia and critical care physicians were formed. One was in a rest group, RG (after a 48-hours weekend without hospital work) and the other in Sleep Deprivation Group (SDG) after a 24 h-consecutives-shift. Changes in medical reasoning’s performance were measured by 69-items script concordance tests (SCT) through to the two tests. Group A completed the first part of the assessment (Set A) after a weekend without work and the second part (Set B) after a 24 h-shift; group B did the same in reverse order. The primary outcome was medical reasoning’s performance as measured by SCT in RG and SDG. The secondary outcomes included association between the performance with the demographic data, variation of the KSS (Karolinska sleepiness scale) daytime alertness score, the number of 24 h-shift during the previous 30 days, the vacations during the previous 30 days, the presence of more or less than 4 h consecutives hours slept, the management of a stressful event during the shift, the different resident years, the place where the shift took place (University hospital or general hospitals) and the type of shift (anaesthesia or intensive care).Results84 physicians (26 physicians and 58 residents) were included. RG exhibited significantly higher performance scores than SDG (68 ± 8 vs. 65 ± 9, respectively; p = 0.008). We found a negative correlation between the number of 24 h-shifts performed during the previous month and the variation of medical reasoning’s performance and no significant variation between professionals who slept 4 h or less and those who slept more than 4 h consecutively during the shift (-4 ± 11 vs. -2 ± 11; p = 0.42).ConclusionOur study suggests that medical reasoning’ performance of anaesthesiologists, measured by the SCT, is reduced after 24 h-shift than after rest period. Working long consecutive hours’ and many shifts should be avoided to prevent the occurrence of medical errors.

Clinical characteristics, treatment strategy, and clinical outcomes in type 2 intestinal failure

Objective: To evaluate the characteristics, clinical management and clinical outcomes of type 2 intestinal failure (IF). Methods: A descriptive case-control study was carried out. The inclusion criteria were as follows: (1) the diagnosis of IF was performed according to the European Society for Parenteral and Enteral Nutrition (ESPEN) consensus statement. (2) using a requirement for parenteral nutrition (PN) of 28 days or more as surrogate marker. (3) a multidisciplinary team (MDT) included surgeons, nutritionist, pharmacist, stoma therapists, and critical care physicians. (4) complete laboratory data. Patients with type 1 and type 3 IF and those who do not cooperate with follow-up. All the data of 67 type II IF were collected from the database in Sir Run Run Shaw Hospital from Jan 2016 to Dec 2023. The pathophysiology, clinical management, and outcomes of type II IF were analyzed. Results: A total of 67 type II IF were included. The median age was 54 (15-83) with 43 males and 24 females. The body mass index was (17.5±3.8) kg/m2, the incidence of malnutrition was 67.2% (45/67), the incidence of sarcopenia was 74.6% (50/67), the median number of previous surgeries was 2.0 (1-13), and the median duration time of PN was 2.1 (1-12) months. The underlying disease of type 2 IF included 36 Crohn`s disease, 2 ulcerative colitis, 3 radiation enteritis, 2 intestinal Behcet's disease, 4 mesenteric infarction, 1 aggressive fibromatosis, 5 abdominal cocoon syndrome, 5 gastrointestinal perforation, 1 hernia, 4 intestinal dysmotility, and 4 other reasons (gastrointestinal tumor, trauma, and non-Hodgkin's lymphoma). According to the pathophysiology of IF, there were 33 intestinal fistula, 12 intestinal dysmotility, 6 mechanical obstruction, 13 short bowel syndrome, and 3 extensive small bowel mucosal disease. After treatment with MDT, 67 patients with type 2 IF received nutritional support therapy for intestinal rehabilitation treatment, of which 36 patients recovered with oral diet or enteral nutrition, 31 patients underwent reconstructive surgery after intestinal rehabilitation treatment failure. The median duration time of reconstructive surgery was 2.7 (1-9) months. 24 patients recovered intestinal autonomy after surgery, with 7 deaths, including 6 deaths due to abdominal infections and 1 case of intestinal dysmotility with abiotrophy and liver failure. Conclusion: Standardized multidisciplinary treatment plays an important role in type II intestinal failure, and it promotes patients with intestinal failure regain enteral autonomy.

Adolescents and Young Adults With Respiratory Failure in U.S. PICUs: A Pediatric Health Information System Database Study, 2011–2022

Objectives: To examine the clinical characteristics, outcomes, and resource use of adolescents and young adults (AYAs) admitted to PICUs in the United States with respiratory failure. Design: Retrospective cohort study. Setting: De-identified data from 48 U.S. children’s hospitals contributing to the Pediatric Health Information System (PHIS) database. Patients: All patients older than 30 days old with respiratory failure, defined as encounters with clinical transaction codes for noninvasive or invasive mechanical ventilation, admitted to PHIS database PICUs from January 2011 to December 2022. Patients were categorized into five cohorts (< 15, 15–18, 19–21, 22–25, and > 25 yr old). Interventions: None. Measurements and Main Results: A total of 430,238 patients were identified. AYA (≥ 15 yr old) accounted for 15% (65,740) of all PICU admissions with respiratory failure. Forty-nine percent (32,232/65,740) of AYA older than 25 years had medical technology dependence compared with 39% in those younger than 15 years (p < 0.001). Sixty-one percent of AYA older than 25 years had a cardiovascular comorbidity compared with 35% of those younger than 15 years (p < 0.001). Forty percent of AYA older than 25 years had a neurologic comorbidity, and 27% a gastrointestinal comorbidity, compared with 27% and 31%, respectively, in those younger than 15 years (all p < 0.001). Compared with those younger than 15 years, AYA median hospital crude mortality rate was higher at 7.7% compared with 5.2%, as were median hospital charges per encounter at $163K (interquartile range [IQR], $77K–$350K) vs. $121K (IQR, $53K–$278K; all p < 0.001). Median ventilator days and hospital length of stay in survivors were similar for all age cohorts. Conclusions: AYA represent a substantial proportion of patients admitted to the PICU with respiratory failure. These individuals have unique comorbidities and are at risk for increased mortality and resource utilization compared with younger patients during hospitalization. Medical complexity and sequelae of pediatric illness may delay the transition of AYA to adult care, necessitating collaboration between adult and pediatric critical care physicians to increase research across the age spectrum and develop and implement appropriate evidence-based guidelines.

Pre-hospital 'dirty adrenaline': A descriptive case series of patients receiving peripheral dilute adrenaline infusions in Central Australian remote nurse-led clinics prior to aeromedical retrieval.

'Dirty adrenaline' is the informal term used for a rapidly made peripheral dilute adrenaline infusion in the emergency treatment of shock, most commonly 1 mg adrenaline in 1 L 0.9% NaCl. It has long been part of the remote clinician's arsenal despite no supporting scientific literature. Remote clinics in Central Australia can be hours away from critical care support. The region's high prevalence of renal and cardiac disease means that access to early vasopressors and inotropes is a necessity for treating shock. To tackle this, remote clinicians often use 'dirty adrenaline'. We present a review of 'dirty adrenaline' use in this region. Central Australian Retrieval Service's database was screened to identify cases in which a peripheral dilute adrenaline infusion was administered in a remote clinic prior to patient aeromedical retrieval. A retrospective chart review collected: patient demographics; clinical characteristics; infusion details; adverse events; hospital lengths of stay; and mortality outcomes. Fifty-seven cases were identified. Median patient age was 50 (range: 2-96). Septic shock was the most common clinical indication (40/57). Median infusion duration was 155 min. Median systolic BP from commencement until retrieval increased from 75.5 to 91 mmHg. Survival to hospital discharge was 86% (49/57). No significant adverse events associated with 'dirty adrenaline' were recorded. 'Dirty adrenaline' is safe to administer and appears to considerably improve survival when used to treat fluid-resistant shock in remote nurse-led clinics guided by an off-site critical care physician.

A Common Longitudinal Intensive Care Unit data Format (CLIF) to enable multi-institutional federated critical illness research.

Critical illness, or acute organ failure requiring life support, threatens over five million American lives annually. Electronic health record (EHR) data are a source of granular information that could generate crucial insights into the nature and optimal treatment of critical illness. However, data management, security, and standardization are barriers to large-scale critical illness EHR studies. A consortium of critical care physicians and data scientists from eight US healthcare systems developed the Common Longitudinal Intensive Care Unit (ICU) data Format (CLIF), an open-source database format that harmonizes a minimum set of ICU Data Elements for use in critical illness research. We created a pipeline to process adult ICU EHR data at each site. After development and iteration, we conducted two proof-of-concept studies with a federated research architecture: 1) an external validation of an in-hospital mortality prediction model for critically ill patients and 2) an assessment of 72-hour temperature trajectories and their association with mechanical ventilation and in-hospital mortality using group-based trajectory models. We converted longitudinal data from 94,356 critically ill patients treated in 2020-2021 (mean age 60.6 years [standard deviation 17.2], 30% Black, 7% Hispanic, 45% female) across 8 health systems and 33 hospitals into the CLIF format, The in-hospital mortality prediction model performed well in the health system where it was derived (0.81 AUC, 0.06 Brier score). Performance across CLIF consortium sites varied (AUCs: 0.74-0.83, Brier scores: 0.06-0.01), and demonstrated some degradation in predictive capability. Temperature trajectories were similar across health systems. Hypothermic and hyperthermic-slow-resolver patients consistently had the highest mortality. CLIF facilitates efficient, rigorous, and reproducible critical care research. Our federated case studies showcase CLIF's potential for disease sub-phenotyping and clinical decision-support evaluation. Future applications include pragmatic EHR-based trials, target trial emulations, foundational multi-modal AI models of critical illness, and real-time critical care quality dashboards.

Arvind Kumar Baronia: A Visionary Indian Academician in Critical Care Medicine.

Dr. Arvind Kumar Baronia, an esteemed academician, devoted his professional life to laying the foundation of the specialty of critical care medicine (CCM) in India in the public sector. His vision and efforts to provide world-class clinical care to patients requiring intensive care units not only led to the establishment of the first standalone department of CCM in the public sector in India but also contributed significantly to formulating a well-structured training course for CCM as well as to get recognition of this specialty as a super-specialty branch of medicine in India. These academic milestones ultimately continue to create a pool of well-trained critical care physicians from various teaching institutes and colleges in India who serve to save thousands of lives of critically ill patients throughout the country.

Monitoring and modulation of respiratory drive in patients with acute hypoxemic respiratory failure in spontaneous breathing.

Non-invasive respiratory support, namely, non-invasive ventilation, continuous positive airway pressure, and high-flow nasal cannula, has been increasingly used worldwide to treat acute hypoxemic respiratory failure, giving the benefits of keeping spontaneous breathing preserved. In this scenario, monitoring and controlling respiratory drive could be helpful to avoid patient self-inflicted lung injury and promptly identify those patients that require an upgrade to invasive mechanical ventilation. In this review, we first describe the physiological components affecting respiratory drive to outline the risks associated with its hyperactivation. Further, we analyze and compare the leading strategies implemented for respiratory drive monitoring and discuss the sedative drugs and the non-pharmacological approaches used to modulate respiratory drive during non-invasive respiratory support. Refining the available techniques and rethinking our therapeutic and monitoring targets can help critical care physicians develop a personalized and minimally invasive approach.

Echocardiographic image quality deteriorates with the severity of cardiogenic shock

BackgroundTransthoracic echocardiography (TTE) is the primary tool for assessing left ventricular (LV) function in cardiogenic shock (CS). However, inadequate image quality often hinders it. In this retrospective study, we investigated factors associated with LV image quality in patients admitted to the intensive care unit (ICU) with ischemic CS.ResultsTwo critical care physicians accredited in echocardiography independently reviewed the TTEs of 100 patients admitted to our tertiary cardiac ICU with ST-elevation myocardial infarction complicated by CS between October 2016 and September 2019. Endocardial border definition (EBD) was graded for each myocardial segment of the apical 4-chamber and 2-chamber views using a conventional scoring system (1 = good, 2 = suboptimal, 3 = poor, and 4 = not possible). The biplane EBD index (EBDi) was calculated by averaging all segments from both views. An average EBDi of both observers was correlated with clinical and echocardiographic parameters. The median age was 62 years [54, 73], and 78% were males. LV ejection fraction and cardiac index (CI) medians were 29% [20, 35] and 1.93 l/min/m2 [1.40, 2.51], respectively. The median biplane EBDi was nearly suboptimal (1.833 [1.542, 2.083]). There was no correlation between EBDi and age, sex, or body mass index. However, biplane EBDi demonstrated statistically significant correlations with PaO2 (r2 = 0.066, p = 0.01), mean arterial pressure (MAP, r2 = 0.055, p = 0.03), CI (r2 = 0.105, p < 0.01), tricuspid annulus systolic velocity (RV S’, r2 = 0.092, p = 0.01), and tricuspid regurge maximum velocity (TR Vmax, r2 = 0.067, p = 0.01). In a multivariate model, only CI correlated independently with EBDi (r2 = 0.105, p < 0.01). The biplane EBDi predicted CI (area under the curve (AUC) 0.70, p = 0.001) with good sensitivity (71%) and reasonable specificity (61%).ConclusionsThe study suggests that in patients admitted to the ICU with ischemic CS, LV image quality by TTE deteriorates with the severity of shock, as indicated by CI.

Workplace support for physicians during the COVID-19 Pandemic: Did it affect burnout?

BackgroundA concern before 2020, physician burnout worsened during the COVID-19 pandemic. Little empirical data are available on pandemic workplace support interventions or their influence on burnout. We surveyed a national sample of frontline physicians on burnout and workplace support during the pandemic.MethodsWe surveyed a stratified random sample of 12,833 US physicians most likely to care for adult COVID-19 patients from the comprehensive AMA Physician Professional Data ™ file. The sample included 6722 primary care physicians (3331 family physicians, 3391 internists), 880 hospitalists, 1783 critical care physicians (894 critical care physicians, 889 pulmonary intensivists), 2548 emergency medicine physicians, and 900 infectious disease physicians. The emailed survey elicited physicians’ perceptions of organizational interventions to provide workplace support and/or to address burnout. Burnout was assessed with the Professional Fulfillment Index Burnout Composite scale (PFI-BC). Proportional specialty representation and response bias were addressed by survey weighting. Logistic regression assessed the association of physician characteristics and workplace interventions with burnout.ResultsAfter weighting, respondents were representative of the total sample. Overall physician burnout was 45.4%, significantly higher than in our previous survey. Open-ended responses mentioned that staffing shortages (physician, nursing, and other staff) combined with the increased volume, complexity, and acuity of patients during the pandemic increased job demands. The most frequent workplace support interventions were direct pandemic control measures (increased access to personal protective equipment, 70.0%); improved telehealth functionality (43.4%); and individual resiliency tools (yoga, meditation, 30.7%). Respondents placed highest priority on workplace interventions to increase financial support and increase nursing and clinician staffing. Factors significantly associated with lower odds of burnout were practicing critical care (compared with emergency medicine) OR 0.33 (95% CI 0.12 – 0.93), improved telehealth functionality OR 0.47 (95% CI 0.23 – 0.97) and being in practice for 11 years or longer OR 0.44 (95% CI 0.19–0.99).ConclusionsBurnout across frontline specialties increased during the pandemic. Physician respondents focused on inadequate staffing in the context of caring for more and sicker patients, combined with the lack of administrative efforts to mitigate problems. Burnout mitigation requires system-level interventions beyond individual-focused stress reduction programs to improve staffing, increase compensation, and build effective teams.

Demand for rating and prognostic scales among anesthesiologists and critical care physicians of Russian Federation: a survey

Demand for rating and prognostic scales among anesthesiologists and critical care physicians of Russian Federation: a survey

Evolution and Effects of Ad Hoc Multidisciplinary Team Meetings in the Emergency Intensive Care Unit: A Five-Year Analysis.

Background: Multidisciplinary team meetings (MDTMs) are crucial in the ICU. However, daily rounds may not address all sensitive issues due to time constraints and the complexity of cases. This study aimed to describe detailed information and characteristics of ad hoc MDTMs in the ICU. Methods: This single-center, retrospective study analyzed adult emergency ICU admissions at Okayama University Hospital from 1 January 2019 to 31 December 2023. During this period, weekly regular multidisciplinary team ICU rounds were introduced in June 2020, and regular weekday morning MDTMs began in April 2022. A multiple logistic regression analysis was applied to determine the impact of these changes on the frequency of ad hoc MDTMs, adjusting for variables including annual changes. Results: The study analyzed 2487 adult EICU patients, with a median age of 66, and 63.3% of them male. MDTMs were held for 168 patients (6.8%), typically those with severe conditions, including higher COVID-19 prevalence and APACHE II scores, and longer ICU stays. Despite a constant total number of MDTMs, the likelihood of conducting ad hoc MDTMs increased annually (adjusted OR 1.19; 95% CI, 1.04-1.35). Of the 329 MDTMs conducted for these patients, 59.0% addressed end-of-life care, involving an average of 11 participants, mainly nurses and emergency and critical-care physicians. Conclusions: Changes in ICU round and meeting structures might be associated with a higher frequency of conducting ad hoc MDTMs, highlighting their evolving role and importance in patient care management.

Nonsteroidal anti-inflammatory drugs for analgesia in intensive care units: a survey of Canadian critical care physicians.

Opioids remain the mainstay of analgesia for critically ill patients, but its exposure is associated with negative effects including persistent use after discharge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be an effective alternative to opioids with fewer adverse effects. We aimed to describe beliefs and attitudes towards the use of NSAIDs in adult intensive care units (ICUs). Our survey of Canadian ICU physicians was conducted using a web-based platform and distributed through the Canadian Critical Care Society (CCCS) email distribution list. We used previously described survey development methodology including question generation and reduction, pretesting, and clinical sensibility and pilot testing. We received 115 completed surveys from 321 CCCS members (36%). Nonsteroidal anti-inflammatory drugs use was most described as "rarely" (59 respondents, 51%) with the primary concern being adverse events (acute kidney injury [108 respondents, 94%] and gastrointestinal bleeding [92 respondents, 80%]). The primary preferred analgesic was acetaminophen (75 respondents, 65%) followed by opioids (40 respondents, 35%). Most respondents (91 respondents, 80%) would be willing to participate in a randomized controlled trial examining NSAID use in critical care. In our survey, Canadian critical care physicians did not mention commonly using NSAIDs primarily because of concerns about adverse events. Nevertheless, respondents were interested in further studying ketorolac, a commonly used NSAID outside of the ICU, in critically ill patients.

Physician and Practice Characteristics Influencing Telemedicine Uptake Among Frontline Clinicians in the Early COVID-19 Pandemic Response: National Survey Study.

Telemedicine expanded rapidly during the COVID-19 pandemic, as key policy changes, financial support, and pandemic fears tipped the balance toward internet-based care. Despite this increased support and benefits to patients and clinicians, telemedicine uptake was variable across clinicians and practices. Little is known regarding physician and institutional characteristics underlying this variability. This study aimed to evaluate factors influencing telemedicine uptake among frontline physicians in the early pandemic response. We surveyed a national stratified sample of frontline clinicians drawn from the American Medical Association Physician Professional Data in June or July 2020. The survey inquired about the first month and most recent month (June 2020) of pandemic telemedicine use; sample data included clinician gender, specialty, census region, and years in practice. Local pandemic conditions were estimated from county-level data on COVID-19 rates at the time of survey response. Data were analyzed in a weighted logistic regression, controlling for county-specific pandemic data, and weighted to account for survey data stratification and nonresponse. Over the first 3-4 months of the pandemic, the proportion of physicians reporting use of telemedicine in >30% of visits increased from 29.2% (70/239) to 35.7% (85/238). Relative to primary care, odds of substantial telemedicine use (>30%) both during the first month of the pandemic and in June 2020 were increased among infectious disease and critical care physicians and decreased among hospitalists and emergency medicine physicians. At least minimal prepandemic telemedicine use (odds ratio [OR] 11.41, 95% CI 1.34-97.04) and a high 2-week moving average of local COVID-19 cases (OR 10.16, 95% CI 2.07-49.97) were also associated with substantial telemedicine use in June 2020. There were no significant differences according to clinician gender, census region, or years in practice. Prepandemic telemedicine use, high local COVID-19 case counts, and clinician specialty were associated with higher levels of substantial telemedicine use during the early pandemic response. These results suggest that telemedicine uptake in the face of the pandemic may have been heavily influenced by the level of perceived threat and the resources available for implementation. Such understanding has important implications for reducing burnout and preparation for future public health emergencies.

Surgical outreach for the Americas: a self-sustainable model for partnership and education.

It is estimated that up to 28% of global disease burden is surgical with hernias representing a unique challenge as the only definitive treatment is surgery. Surgical Outreach for the Americas (SOfA) is a nongovernmental organization focused primarily on alleviating the disease burden of inguinal and umbilical hernias in Central America. We present the experience of SOfA, a model focused on partnership and education. SOfA was established in 2009 to help individuals recover from ailments that are obstacles to working and independent living. Over the past 15years, SOfA has partnered with local healthcare providers in the Dominican Republic, El Salvador, Honduras, and Belize. The SOfA team consists of surgeons, surgery residents, triage physicians, an anesthesiologist, anesthetists, operating room nurses, recovery nurses, a pediatric critical care physician, sterile processing technicians, interpreters, and a team coordinator. Critical partnerships required include the CMO, internal medicine, general surgery, nursing, rural health coordinators and surgical training programs at public hospitals. SOfA has completed 24 trips, performing 2074 procedures on 1792 patients. 71.4% of procedures were hernia repairs. To enhance sustainability of healthcare delivery, SOfA has partnered with the local facilities through capital improvements to include OR tables, OR lights, anesthesia machines, monitors, hospital beds, stretchers, sterilizers, air conditioning units, and electrosurgical generators. A lecture series and curriculum on perioperative care, anesthesia, anatomy, and operative technique is delivered. Local surgery residents and medical students participated in patient care, learning alongside SOfA teammates. Recently, SOfA has partnered with SAGES Global Affairs Committee to implement a virtual Global Laparoscopic Advancement Program, a simulation-based laparoscopic training curriculum for surgeons in El Salvador. A sustainable partnership to facilitate surgical care in low resource settings requires longitudinal, collaborative relationships, and investments in capital improvements, education, and partnership with local healthcare providers, institutions, and training programs.

Application of a cloud platform that identifies patient-ventilator asynchrony and enables continuous monitoring of mechanical ventilation in intensive care unit

BackgroundPatient-ventilator asynchrony (PVA) frequently occurs in mechanically ventilated patients within the ICU and has the potential for harm. Depending solely on the health care team cannot accurately and promptly identify PVA. To address this issue, our team has developed a cloud-based platform for monitoring mechanical ventilation (MV), comprising the PVA-RemoteMonitor system and the 24-h MV analysis report. We conducted a survey to evaluate physicians' satisfaction and acceptance of the platform in 14 ICUs. MethodsData from medical records, clinical information systems, and ventilators were uploaded to the cloud platform and underwent data processing. The data were analyzed to monitor PVA and displayed in the front-end. The 24-h analysis report for MV was generated for clinical reference. Critical care physicians in 14 hospitals' ICUs that involved in the platform participated in a questionnaire survey, among whom 10 physicians were interviewed to investigate physicians’ acceptance and opinions of this system. ResultsThe PVA-RemoteMonitor system exhibited a high level of specificity in detecting flow insufficiency, premature cycle, delayed cycle, reverse trigger, auto trigger, and overshoot, with sensitivities of 90.31 %, 98.76 %, 99.75 %, 99.97 %, 100 %, and 99.69 %, respectively. The 24-h analysis report supplied essential data about PVA and respiratory mechanics. 86.2 % (75/87) of physicians supported the application of this platform. ConclusionsThe PVA-RemoteMonitor system accurately identified PVA, and the MV analysis report provided guidance in controlling PVA. Our platform can effectively assist ICU physicians in the management of ventilated patients.

Maladaptive personality traits are associated with burnout risk in Italian anesthesiologists and intensivists: a secondary analysis from a cross-sectional study

BackgroundBurnout is a maladaptive response to chronic stress, particularly prevalent among clinicians. Anesthesiologists are at risk of burnout, but the role of maladaptive traits in their vulnerability to burnout remains understudied.MethodsA secondary analysis was performed on data from the Italian Association of Hospital Anesthesiologists, Pain Medicine Specialists, Critical Care, and Emergency (AAROI-EMAC) physicians. The survey included demographic data, burnout assessment using the Maslach Burnout Inventory (MBI) and subscales (emotional exhaustion, MBI-EE; depersonalization, MBI-DP; personal accomplishment, MBI-PA), and evaluation of personality disorders (PDs) based on DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) criteria using the assessment of DSM-IV PDs (ADP-IV). We investigated the aggregated scores of maladaptive personality traits as predictor variables of burnout. Subsequently, the components of personality traits were individually assessed.ResultsOut of 310 respondents, 300 (96.77%) provided complete information. The maladaptive personality traits global score was associated with the MBI-EE and MBI-DP components. There was a significant negative correlation with the MBI-PA component. Significant positive correlations were found between the MBI-EE subscale and the paranoid (r = 0.42), borderline (r = 0.39), and dependent (r = 0.39) maladaptive personality traits. MBI-DP was significantly associated with the passive-aggressive (r = 0.35), borderline (r = 0.33), and avoidant (r = 0.32) traits. Moreover, MBI-PA was negatively associated with dependent (r = − 0.26) and avoidant (r = − 0.25) maladaptive personality features.ConclusionsThere is a significant association between different maladaptive personality traits and the risk of experiencing burnout among anesthesiologists. This underscores the importance of understanding and addressing personality traits in healthcare professionals to promote their well-being and prevent this serious emotional, mental, and physical exhaustion state.

Blood Pressure Management in Early Aneurysmal Subarachnoid Hemorrhage: A National Cross-Sectional Survey of Canadian Intensivists and Cerebrovascular Neurosurgeons.

In aneurysmal subarachnoid hemorrhage (aSAH), rebleeding of the culprit aneurysm is associated with significant morbidity and mortality. Blood pressure reduction to specific target levels, with the goal of preventing rebleeding, has been a mainstay of care prior to definitively securing the aneurysm. Clinical practice guidelines have recently changed and no longer recommend specific blood pressure targets. This survey aims to identify the reported practice patterns and beliefs regarding blood pressure management during the early phase of aSAH. We conducted a self-administered, Web-based survey of critical care physicians and cerebrovascular neurosurgeons practicing in Canada. The questionnaire contained 21 items, including 3 case-based scenarios to elicit blood pressure target selection, both before and after aneurysm securing. In the presecured period, systolic blood pressures of 160 mm Hg (50% [144 of 287]) and 140 mm Hg (42% [120 of 287]) were the most frequently selected upper-limit targets. In the postsecured period, a systolic blood pressure of 180 mm Hg (32% [93 of 287]) was the most frequently selected upper-limit target, but there was a wide distribution of targets selected across all three cases ranging from 100 to > 200 mm Hg. A mean arterial pressure of 65 mm Hg was the most common lower-limit target in both the presecured and postsecured periods. There was little change in blood pressure targets with increasing clinical severity. Predictors of higher or lower blood pressure target selection and barriers to implementation of the desired target were identified. During the presecured period, nearly half of the reported upper-limit blood pressure targets are lower than previous guideline recommendations. These targets remain consistent despite increasing clinical severity and could potentially exacerbate cerebral ischemia and negatively impact clinical outcomes. In the postsecured period, there is wide variation in the reported blood pressure targets. A clinical trial is urgently needed to guide decision-making.