Critical Care Providers Research Articles

Implementation of a pediatric critical care focused bedside ultrasound training program in a large academic PICU.

To determine the feasibility and describe the process of implementing a pediatric critical care bedside ultrasound program in a large academic PICU and to evaluate the impact of bedside ultrasound on clinical management. Retrospective case series, description of program implementation. Single-center quaternary noncardiac PICU in a children's hospital. Consecutive patients from January 22, 2012, to July 22, 2012, with bedside ultrasounds performed and interpreted by pediatric critical care practitioners. A pediatric critical care bedside ultrasound program consisting of a 2-day immersive course followed by clinical performance with internal quality assurance review was implemented. Studies performed in the PICU following training were documented and reviewed against reference standards including subspecialist-performed ultrasound or clinical response. Seventeen critical care faculties and eight fellows recorded 201 bedside ultrasound studies over 6 months in defined core applications: 57 procedural (28%), 76 hemodynamic (38%), 35 thoracic (17%), and 33 abdominal (16%). A quality assurance review identified 23 studies (16% of all nonprocedural studies) as critical (affected clinical management or gave valuable information). Forty-eight percent of those studies (11/23) were within the hemodynamic core. The proportion of critical studies were not significantly different across the applications (hemodynamic, 11/76 [15%] vs thoracic and abdominal, 12/68 [18%]; p = 0.65). Examples of critical studies include evidence of tamponade secondary to pleural effusions, identification of pulmonary hypertension, hemodynamic assessment before tracheal intubation, recognition of hypovolemia and systemic vascular resistance abnormalities, determination of pneumothorax, location of chest tube and urinary catheter, and differentiation of pleural fluid from pulmonary consolidation. Implementation of a critical care bedside ultrasound program for critical care providers in a large academic PICU is feasible. Bedside ultrasound evaluation and interpretation by intensivists affected the management of critically ill children.

Useful but not used: pediatric critical care physician views on bedside ultrasound.

The purpose of this study was to assess the learning needs of pediatric critical care (PCC) physicians in bedside ultrasound (BUS) use. This was a survey-based study conducted at an academic center with a PCC fellowship program. We surveyed PCC fellows and faculty to elicit their views on BUS and asked them about the frequency of use, their perception of the clinical utility, and their level of confidence in performing different BUS applications. There was no statistical difference in the self-reported use of BUS applications in the faculty and fellows, except for cardiac arrest, which 66.7% of the faculty used but none of the fellows did (P < 0.05). There were no statistically significant differences between perceived usefulness and confidence in the performance of BUS applications between the fellows and faculty. The largest gaps between perceived usefulness and confidence in performing BUS applications were for left ventricle ejection fraction (Δ = 2.72), inferior vena cava collapse (Δ = 2.67), pulmonary edema (Δ = 2.22), and pneumothorax (Δ = 2.11). Pediatric critical care providers report limited confidence in several applications that they perceive as useful and are therefore likely motivated to learn BUS applications. Concentrating curricula on those applications with the greatest differences between usefulness and confidence and building on the confidence of those applications the PCC providers are already using will serve to expand availability and increase use of this high-impact technology.

Impact of a focused transthoracic echocardiography training course for rescue applications among anesthesiology and critical care medicine practitioners: a prospective study.

To investigate the impact of a sequence of educational interventions in a one-day course on focused transthoracic echocardiography (FOTE) by anesthesia and critical care practitioners. A prospective analysis of the educational data. Educational setting in two academic medical centers and a medical meeting workshop organized by one of these institutions. Fifty-six anesthesia and critical care providers, divided into three groups, participated separately in a FOTE training course. All participants received a sequence of educational intervention as follows: A standardized, multiple-choice pretest; a lecture on cardiac and lung ultrasound; and a FOTE "hands-on" training session. The same standardized test was administered and graded as a posttest. Fifty-six professionals attended the course in three separate groups: The first were cardiothoracic anesthesia fellows (n = 16) (group 1), the second included critical care practitioners (n = 21) (group 2), and the third were general anesthesiologists (n = 19) (group 3). Parasternal views were most difficult to obtain for all groups (58.1, 63.8, and 58%, respectively). The mean written test scores increased from 14.9±2 to 21.0±2.3 in group 1; from 12.3±3.8 to 19.2±3.7 in group 2; 12±3.5 to 21±2.4 in group 3, (p = 0.0003, 0.00005, 0.0001, respectively). A FOTE training course improves image acquisition skills and knowledge to the same level independently of professional background and level of experience in critical care ultrasound.

The myth of the workforce crisis. Why the United States does not need more intensivist physicians.

Intensivist physician staffing is associated with lower mortality in the intensive care unit (ICU), yet many ICUs are not staffed by trained intensivists. This gap has led to a number of proposals intended to increase the intensivist supply in the United States. In this perspective we argue that such efforts would be both ineffective and ill-advised. Because many ICU patients are not critically ill, workforce models that base demand projections on ICU admission rather than true critical illness substantially overstate the workforce gap. Even in the presence of a workforce gap, training new intensivists would not place them in hospitals where they are needed most, would not mitigate the shortage of nonphysician critical care providers, and would require a unrealistic increase in spending on physician training. In addition, efforts to train more intensivists require us to prioritize intensive care over other specialties that are also in short supply, without clear justification for why intensivists are more important. Rather than continuing an unwarranted push to increase the intensivist supply, we suggest alternative workforce policies that emphasize novel interprofessional care models (to improve ICU quality in the absence of intensivists) combined with limitations on the future growth of ICU beds (to reduce demand through implicit rationing of care). These policies offer opportunities to reduce the mismatch between critical care supply and demand without an unnecessary expansion of the intensivist supply.

Insulin IP Calc: A smartphone application for insulin infusion protocol in Intensive Care Units.

Sir, Insulin infusion for hyperglycaemia management in the Intensive Care Unit (ICU) is often based on paper-based, complex protocols that are variable rate insulin infusion protocols or sliding scale regimens. The older sliding scale regimens are considered obsolete in current practice, while more complex, validated variable rate algorithms such as the Yale insulin infusion protocol, Portland protocol and University of Washington protocol are increasingly being used in ICUs. The conversion of paper-based protocols to computer-based software protocols may improve adherence and reduce errors in implementation.[1] Goldberg et al. described the ‘Yale Insulin infusion protocol’ an intuitive, structured variable rate insulin infusion protocol for hyperglycaemia management in ICU.[2] The protocol is not tailored for use in diabetic ketoacidosis or hyperglycaemic hyperosmolar states. Numerous subsequent studies have validated this protocol in cardiac surgical and medical ICUs.[3] Older guidelines for hyperglycaemia management emphasised, ‘Tight Control’ insulin infusion regimens that kept blood glucose in the target range of 80–110 mg/dL. Later studies showed an increased risk of major hypoglycaemic events with these lower targets.[4] In view of this, the revised consensus guidelines of the American Association of Clinical Endocrinology and American Diabetes Association recommended a blood glucose target of 140–180 mg/dL.[4] Accordingly, the Yale insulin infusion protocol was modified and updated to a blood glucose target of 120–160 mg/dL by Shetty et al., with a median target of 150 mg/dL.[5] We describe, ‘Insulin IP Calc’, a simple, point of care, Android operating system smartphone application created by us, based on the updated Yale insulin infusion protocol that can be used as a bedside clinical decision support app for insulin infusion management. It can be freely downloaded and installed from its project page http://sourceforge.net/projects/insulinipcalc in an Android-based smartphone or tablet for use at the bedside. The use of software-based variable rate insulin infusion protocols can potentially simplify the implementation of the Yale algorithm by critical care providers. It may also reduce human errors and the incidence of complications such as severe hypoglycaemia, thus decrease the risk of morbidity and mortality. The application, when launched, requires input of an initial blood glucose value in mg/dL, measured by point of care glucometer devices [Figure 1]. The user then calculates the initial insulin infusion rate, which as per algorithm recommends an initial bolus before the infusion. Subsequent values to input include the current (new) blood glucose value (measured at hourly intervals as per protocol, until the values stabilise), the previous blood glucose value and the previous insulin infusion rate. The application then calculates and recommends an action based on the Yale algorithm. It also displays the protocol logic such as a warning to stop insulin infusion due to risk of hypoglycaemia. Future efforts could include the addition of graphical and tabular trends of blood sugar values for an individual patient, reminder alarms for hourly blood glucose measurement and incorporation of updated blood glucose targets. Figure 1 Insulin IP Calc software user interface in Android operating system Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Acute respiratory distress syndrome in an 11-month-old girl leading to extracorporeal membrane oxygenation

Acute respiratory distress syndrome (ARDS) is a condition recognised for al-most fifty years, and is related to high mor-bidity and mortality in children. From its recognition, medical experts tried to make joint efforts to make recommendations and optimize treatment in children and adult population. The new definition of ARDS suggests treatment by introducing three levels of severity, according to PaO2/FiO2 and positive end-expiratory pres-sure. Lung-protective ventilation remains crucial in achieving better outcome in pae-diatric acute respiratory distress syndrome (PARDS), but promising therapies based on paediatric studies include non-invasive ventilation, endotracheal surfactant, high-frequency oscillatory ventilation (HFOV), and use of ECMO as „rescue“ therapy. Nevertheless, PARDS is a real challenge for the paediatric critical care provider, and even if current state-of-the-art treatment methods are delivered, this disease often leads to fatal outcome. We report the case of an 11-month-old female infant who developed ARDS, was treated by current up-to-date treatment methods, including ECMO, and despite this, succumbed to her illness. With this case report we would like once more to bring to consideration the current knowl-edge on etiology, epidemiology, diagnosis and treatment of ARDS in children, and emphasize the high morbidity and mortal-ity related to this syndrome.

Assessment of Critical Care Provider's Application of Preventive Measures for Ventilator-Associated Pneumonia in Intensive Care Units.

The implementation of guidelines for the prevention of Ventilator-associated pneumonia has been shown to have a significant effect in reducing the incidence of VAP. The aim of the present study was to evaluate the implementation of the preventive strategies for VAP in ICUs of university hospitals of Sari, Iran. This cross-sectional study was carried out in 600 beds/day in the ICUs of university hospitals of Sari from April to June 2012. Sampling was done by availability technique in patients receiving mechanical ventilation in the ICU. The implementation of the preventive measures was assessed by a standard checklist with previously approved validity and reliability. The percentage of implementing each of the measures was as follows: sterile suction, 88.44%; semi-recumbent position, 76.8%; oral hygiene, 58.45%; using heat and moisture exchanges (HMEs), 58%; controlling cuff pressure, 46.8%; hand hygiene, 32.8%; using anti-coagulants, 26.8% and physiotherapy, 25.5%. Closed suction system, continuous drainage of subglottic secretions and kinetic beds were not used at all. The overall mean percentage of implementing preventive measures was low and required designing integrated guidelines by considering the conditions of the ICUs in each country, as well as educating and encouraging the staffs to use the recommended guidelines.

The Effect of an Electronic Checklist on Critical Care Provider Workload, Errors, and Performance.

The strategy used to improve effective checklist use in intensive care unit (ICU) setting is essential for checklist success. This study aimed to test the hypothesis that an electronic checklist could reduce ICU provider workload, errors, and time to checklist completion, as compared to a paper checklist. This was a simulation-based study conducted at an academic tertiary hospital. All participants completed checklists for 6 ICU patients: 3 using an electronic checklist and 3 using an identical paper checklist. In both scenarios, participants had full access to the existing electronic medical record system. The outcomes measured were workload (defined using the National Aeronautics and Space Association task load index [NASA-TLX]), the number of checklist errors, and time to checklist completion. Two independent clinician reviewers, blinded to participant results, served as the reference standard for checklist error calculation. Twenty-one ICU providers participated in this study. This resulted in the generation of 63 simulated electronic checklists and 63 simulated paper checklists. The median NASA-TLX score was 39 for the electronic checklist and 50 for the paper checklist (P = .005). The median number of checklist errors for the electronic checklist was 5, while the median number of checklist errors for the paper checklist was 8 (P = .003). The time to checklist completion was not significantly different between the 2 checklist formats (P = .76). The electronic checklist significantly reduced provider workload and errors without any measurable difference in the amount of time required for checklist completion. This demonstrates that electronic checklists are feasible and desirable in the ICU setting.

Caring for the critically ill obese patient: challenges and opportunities.

Obesity remains a challenging public health problem. The anatomic and physiologic complexities of obese patients make their healthcare challenging under routine circumstances, but in the setting of critical illness, these challenges are magnified. This review explores some of the unique difficulties that critical care providers face when caring for the obese patient and highlights areas in which future research is needed to provide optimal care.

Evacuation of the ICU: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Despite the high risk for patient harm during unanticipated ICU evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this article are important for all who are involved in pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. The Evacuation and Mobilization topic panel used the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop seven key questions for which specific literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Based on current best evidence, we provide 13 suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospital and intrahospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System. A three-stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat, and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation, including regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information and tracking, and federal and international evacuation assistance systems, are also provided. Successful ICU evacuation during a disaster requires active preparation, participation, communication, and leadership by critical care providers. Critical care providers have a professional obligation to become better educated, prepared, and engaged with the processes of ICU evacuation to provide a safe continuum of critical care during a disaster.

Variability of DKA Management Among Pediatric Emergency Room and Critical Care Providers: A Call for More Evidence-Based and Cost-Effective Care?

Management protocols have been shown to be effective in the pediatric emergency medicine (PEM) and pediatric critical care (PCC) settings. Treatment protocols define clear goals which are achieved with consistency in implementation. Over the last decade, many new recommendations have been proposed on managing diabetic ketoacidosis (DKA). Although no perfect set of guidelines exist, many institutions are developing DKA treatment protocols. We sought to determine the variability between institutions in implementation of these protocols.

Critical Care Providersʼ Knowledge and Attitudes About Donation After Circulatory Death.

Donation after circulatory death (DCD) has increased the number of transplantable organs in the USA. However, some critical care providers continue to have concerns about DCD. We surveyed 98 critical care providers (67% response rate) at one medical center using a DCD Knowledge Questionnaire (14 true-false items) and a DCD Attitudes Scale (37 statements, 5-point Likert scale, higher scores=more favorable DCD attitudes) to examine the relationship between knowledge, attitudes, and provider characteristics. Providers (52 physicians, 38 nurses, 8 allied health) were 40.1±12 yrs old, 67% female, and 80% white. DCD knowledge scores ranged from 5 to 12 (mean=9.4±1.6). More knowledge was associated with older age (r=0.27, p=0.01), more ICU experience (r=0.31, p=0.002), and more DCD experience (r=0.21, p=0.04). Most providers did not know (% incorrect) that patient or family consent is necessary for pre-mortem cannulation (62%), a patient must be on a ventilator to be considered for DCD (59%), 5 min of continuous pulselessness or asystole must occur before organ recovery can begin (57%), and death must occur within 2 hrs of ventilator withdrawal for donation to proceed (52%). The DCD Attitudes Scale had high internal consistency (Cronbach's α=0.90). Total DCD attitudes scores ranged from 77 to 159 (mean=129.9±16.4). More favorable attitudes were associated with white race (t=2.4, p=0.02) and more DCD experience (r=0.32, p=0.002). While DCD attitudes were generally positive overall (e.g., 89% felt that DCD allows something positive to come from the patient's death), compared to donation after brain death cases, some providers felt that DCD cases are more difficult and less predictable (67%) and place more stress on staff (52%), less comfortable talking to families about DCD (47%), and less comfortable with DCD overall (33%) and with DCD death criteria (39%). Higher knowledge of the institution's DCD policy was associated with more favorable DCD attitudes (r=0.48, p<0.001). Despite a long-standing practice of DCD (>40 years) in this OPO service area, our survey identified knowledge gaps among critical care providers that must be addressed to enhance the acceptance of DCD as a standard of end-of-life care. As a result, the OPO has appointed two associate medical directors with intensivist expertise in DCD to improve the knowledge of critical care providers that can impact attitudes and affirmative decisions enabling DCD.

Management of Acute Myeloid Leukemia in the Intensive Care Setting.

Patients with acute myeloid leukemia (AML) who are newly diagnosed or relapsed and those who are receiving cytotoxic chemotherapy are predisposed to conditions such as sepsis due to bacterial and fungal infections, coagulopathies, hemorrhage, metabolic abnormalities, and respiratory and renal failure. These conditions are common reasons for patients with AML to be managed in the intensive care unit (ICU). For patients with AML in the ICU, providers need to be aware of common problems and how to manage them. Understanding the pathophysiology of complications and the recent advances in risk stratification as well as newer therapy for AML are relevant to the critical care provider.

Vitamin D deficiency in anesthesia department caregivers at the end of winter.

To test whether the vitamin D status of anesthesia department caregivers practicing at high Northern latitudes is compatible with current recommendations, the 25-hydroxyvitamin D (25(OH)D) levels of caregivers at hospitals in Iceland (64°08' N) and in Wisconsin (43°07' N) were compared at the end of winter. Anesthesia department faculty and resident physicians, non-physician anesthetists, and critical care nurses completed a questionnaire, and provided blood samples for analysis of 25(OH)D by reverse-phase high performance liquid chromatography. One hundred and six participants in Iceland and 124 participants in Wisconsin were enrolled. No difference in mean serum 25(OH)D levels between Iceland [70.53 nmol/l, standard deviation (SD) 30.87 nmol/l] and Wisconsin (70.0 nmol/l, SD 30.0 nmol/l) was observed. In Iceland and Wisconsin, 25(OH)D levels below 25 nmol/l were observed in 4.7% and 4.0%, below 50 nmol/l in 34.9% and 25.0%, and below 75 nmol/l in 56.6% and 61.3% of caregivers, respectively. 25(OH)D levels below the 50 nmol/l (20 ng/ml) threshold recommended by the Institute of Medicine and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, and below the 75 nmol/l (30 ng/ml) threshold recommended by The Endocrine Society, are highly prevalent among anesthesia caregivers working at two Northern hospitals at the end of winter who may otherwise not meet criteria to be tested. Anesthesia and critical care providers may wish to determine their 25(OH)D levels and use effective, safe, and low cost supplementation to target a 25(OH)D level compatible with optimal health.

The Evolving Application of Implementation Science in Critical Care*

The Evolving Application of Implementation Science in Critical Care*

The Development of an Internet-Based Knowledge Exchange Platform for Pediatric Critical Care Clinicians Worldwide*

Advances in Internet technology now enable unprecedented global collaboration and collective knowledge exchange. Up to this time, there have been limited efforts to use these technologies to actively promote knowledge exchange across the global pediatric critical care community. To develop an open-access, peer-reviewed, not-for-profit Internet-based learning application, OPENPediatrics, a collaborative effort with the World Federation of Pediatric Intensive and Critical Care Societies, was designed to promote postgraduate educational knowledge exchange for physicians, nurses, and others caring for critically ill children worldwide. Description of program development. International multicenter tertiary pediatric critical care units across six continents. Multidisciplinary pediatric critical care providers. A software application, providing information on demand, curricular pathways, and videoconferencing, downloaded to a local computer. In 2010, a survey assessing postgraduate educational needs was distributed through World Federation of Pediatric Intensive and Critical Care Societies to constituent societies. Four hundred and twenty-nine critical care providers from 49 countries responded to the single e-mail survey request. Respondents included 68% physicians and 28% nurses who care for critically ill children. Fifty-two percent of respondents reported accessing the Internet at least weekly to obtain professional educational information. The five highest requests were for educational content on respiratory care [mechanical ventilation] (48% [38%]), sepsis (28%), neurology (25%), cardiology (14%), extracorporeal membrane oxygenation (10%), and ethics (8%). Based on these findings, and in collaboration with researchers in adult learning and online courseware, an application was developed and is currently being used by 770 registered users in 60 countries. We describe here the development and implementation of an Internet-based application which is among the first efforts designed to promote global knowledge exchange for physicians and nurses caring for critically ill children. This application has the potential to evolve new methods in postgraduate education. Ongoing assessment of the efficacy of Internet-based learning platforms will be necessary.

Is It Still Cool to Cool? Interpreting the Latest Hypothermia for Cardiac Arrest Trial: March 2014 Annals of Emergency Medicine Journal Club

1.The authors reference 2 previous trials2,3 that compared therapeutic hypothermia (32°C to 34°C [89.6F to 93.2F] for 12 to 24 hours) with standard treatment and “showed a significant improvement in neurologic function and survival with therapeutic hypothermia.”1AWhat was the treatment effect in the previous 2 studies? What percentage of patients had neurologically intact survival? How many patients would one need to treat with hypothermia to produce 1 additional neurologically intact patient?BThere is good evidence that the presence of an initial shockable rhythm greatly enhances the probability of survival from cardiac arrest. Have any randomized trials demonstrated an improvement in neurologic outcomes in patients whose initial rhythm was pulseless electrical activity or asystole?2.Previous studies have reported deleterious effects when patients recovering from an out-of-hospital cardiac arrest develop fever,1,4,5 leading authors to question whether reported benefits are due to hypothermia or prevention of hyperthermia.1 The authors conducted a multicenter, international trial that randomized unconscious adults, who had return of spontaneous circulation after out-of-hospital cardiac arrest, to either 33°C or 36°C (91.4F or 96.8F) temperature target.AThe current recommendation by many expert consensus groups is to cool out-of-hospital cardiac arrest victims to 32°C to 34°C (89.6F to 93.2F) after ventricular fibrillation and possibly other rhythms. The authors did not follow this recommendation for one of the arms of the study. Do you believe there was equipoise? Discuss the importance of equipoise in clinical research.BCould this trial have been performed in the United States? What additional requirements would the investigators have to complete to receive institutional review board approval for exception from informed consent?CThe authors note the inability to blind the critical care practitioners; however, they were able to blind the assessors providing follow-up neurologic examination. Were the methods used to eliminate the risk of critical care provider bias sufficient?3.The authors examined the primary outcome of survival time and followed patients up to the end of the trial (ie, 180 days after the enrollment of the last patient) and powered the study to this outcome.AThe trial was designed as a superiority trial to detect a 20% reduction in the hazard ratio for death with hypothermia at 33°C (91.4F) versus a control group at 36°C (96.8F). Was the study appropriately powered for this outcome?BHow would the power calculations change if the study design were a noninferiority trial of relative normothermia at 36°C (96.8F) versus hypothermia at 33°C (91.4F)?CWhat were the secondary outcomes? Discuss the advantages and disadvantages of using composite outcomes in medical research.DTherapeutic hypothermia causes many physiologic changes and potential dangers to the patient. Therefore, the authors also collected the incidence of predefined serious adverse events up to day 7 in the ICU. Which specific adverse events did they collect? Do you think these adverse events and 7-day interval were sufficient? If not, what other events or intervals might you have chosen?ETo evaluate neurologic outcomes, the authors used the Cerebral Performance Category (CPC) and the modified Rankin score (mRS). For scores to be effective, they should be already validated. Have these 2 scores been previously validated? Are there other scores that the authors could have used?4.For analysis of their results, hazard ratios were used for the analysis of the primary outcome (end-of-trial mortality), but risk ratios were used to analyze the secondary outcomes (CPC score, mRS). What are the differences between hazard ratios and risk ratios? Why did the authors use different tests to analyze their primary and secondary outcomes?5.If you were creating a cardiac arrest protocol in your hospital, what would you set for the target temperature? Do you think the temperature or the protocol is more important for survival?

Care of terminally-ill patients: an opinion survey among critical care healthcare providers in the Middle East.

Modern medicine has allowed physicians to support the dying terminally-ill patient with artificial means. However, a common dilemma faced by physicians in general, and intensivist in particular is when to limit or withdraw aggressive intervention. To study the effect of training background and seniority on Do-not to resuscitate (DNR) decisions in the Middle East. Anonymous questionnaire sent to members of the Pan Arab Society of Critical Care. The response rate was 46.2%. Most of the responders were Muslim (86%) and consultants (70.9%). Majority of the responders were trained in western countries. Religion played a major role in 59.3% for making the DNR decision. DNR was considered equivalent to comfort care by 39.5%. In a futile case scenario, Do Not Escalate Therapy was preferred (54.7%). The likelihood of a patient, once labeled DNR, being clinically neglected was a concern among 46.5%. Admission of DNR patients to the ICU was acceptable for 47.7%. Almost one-half of the responders (46.5%) wanted physicians to have the ultimate authority in the DNR decision. Training background was a significant factor affecting the interpretation of the term no code DNR (P< 0.008). Training background and level of seniority in critical care provider does not impact opinion on most of end of life issues related to care of terminally-ill patients. However, DNR is considered equivalent to comfort care among majority of Middle Eastern trained physicians.

Disaster preparedness, pediatric considerations in primary blast injury, chemical, and biological terrorism.

Both domestic and foreign terror incidents are an unfortunate outgrowth of our modern times from the Oklahoma City bombings, Sarin gas attacks in Japan, the Madrid train bombing, anthrax spores in the mail, to the World Trade Center on September 11(th), 2001. The modalities used to perpetrate these terrorist acts range from conventional weapons to high explosives, chemical weapons, and biological weapons all of which have been used in the recent past. While these weapons platforms can cause significant injury requiring critical care the mechanism of injury, pathophysiology and treatment of these injuries are unfamiliar to many critical care providers. Additionally the pediatric population is particularly vulnerable to these types of attacks. In the event of a mass casualty incident both adult and pediatric critical care practitioners will likely be called upon to care for children and adults alike. We will review the presentation, pathophysiology, and treatment of victims of blast injury, chemical weapons, and biological weapons. The focus will be on those injuries not commonly encountered in critical care practice, primary blast injuries, category A pathogens likely to be used in terrorist incidents, and chemical weapons including nerve agents, vesicants, pulmonary agents, cyanide, and riot control agents with special attention paid to pediatric specific considerations.

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Introduction: A staggering 1 in 5 U.S. patients will die in the intensive care unit setting. Many critical care providers and ICUs are not adequately trained or skilled at providing appropriate focused comfort measure end of life (EOL) care. We previously published our efforts at improving EOL care and goals of care discussions in the ICU setting. As part of this process, we created a focused comfort measures only, computer order entry-set (CMO/COE). Our goal is to provide patient-centered comfort care and reduce painful interventions as we allow natural death. Methods: This study was done at an academic tertiary surgical/trauma/mixed 36-bed ICU with an average of 14 deaths per month. A multidisciplinary EOL critical care team created a standardized CMO/COE with accompanying staff education prior to implementation. All comfort care patients that expired from 3 months in subsequent calendar years (to obtain cohorts of "pre" and "post" CMO order-set patients) had their charts de-identified and evaluated by an independent reviewer for specific EOL patient care. The data was subsequently compiled and compared. Results: We identified 18 deceased patients in each group. CMO/COE was shown to reduce painful interventions in 43% of patients. Of note, 7 patients in the post CMO/COE cohort group did not have the focused CMO order set used and 71% of this subgroup suffered painful interventions. Pain scores demonstrated better symptom control in 13% of patients in the CMO/COE cohort. We also noted deeper sedation scores in 11% of CMO/COE patients. Restraints were discontinued in all of the patients (100%) with the order set employed in the CMO/COE intervention group. Conclusions: A focused CMO/COE does improve EOL patient care in the critical care setting by reducing the number of painful patient interventions and discontinuing patient restraints. A trend towards improved pain and sedation symptom management was also noted in our sample.