Critical Care Specialists Research Articles

Experience with percutaneous dilational tracheostomy.

Percutaneous dilational tracheostomy (PDT) has gained popularity among critical care specialists in the past 10 years. The initial studies in our specialty resulted in essentially banning the procedure as a dangerous substitute for standard operative tracheostomy. Despite this action, more than 1,100 cases of percutaneous tracheostomy have been reported with details on complications. We reviewed all published data and studied 311 patients of our own. A prospective study was performed in 3 groups of patients: 1) 50 patients scheduled for PDT performed in the operating room by a head and neck surgeon (group 1); 2) 50 patients who underwent standard operative tracheostomy performed by the same surgeon (group 2); and 3) 211 patients who underwent bedside PDT by critical care physicians (group 3). The intraoperative complication rates were 0% in group 1, 2% in group 2, and 4% in group 3; the postoperative complication rates were 13%, 4%, and 12%, respectively. There were 2 deaths in group 3, and none in groups 1 or 2. The statistically significant differences among the groups were the superiority of group I over group 3 in intraoperative complications, as well as the lower postoperative complication rate of the standard tracheostomy group. These results show that PDT can be performed with acceptable morbidity rates in relation to published complication rates of standard tracheostomy, but it has no advantage over standard tracheostomy with respect to postoperative morbidity. When they are performed by a head and neck surgeon, the morbidity associated with both standard and percutaneous tracheostomies can be reduced.

The development of competency standards for specialist critical care nurses.

In defining the contemporary role of the specialist nurse it is necessary to challenge the concept of nursing as merely a combination of skills and knowledge. Nursing must be demonstrated and defined in the context of client care and include the broader notions of professional development and competence. This qualitative study sought to identify the competency standards for nurse specialists in critical care and to articulate the differences between entry-to-practice standards and the advanced practice of specialist nurses. Over 800 hours of specialist critical care nursing practice were observed and grouped into 'domains' or major themes of specialist practice using a constant comparison qualitative technique. These domains were further refined to describe attributes of the registered nurses which resulted in effective and/or superior performance (competency standards) and to provide examples of performance (performance criteria) which met the defined standard. Constant comparison of the emerging domains, competency standards and performance criteria to observations of specialist critical care practice, ensured the results provided a true reflection of the specialist nursing role. Data analysis resulted in 20 competency standards grouped into six domains: professional practice, reflective practice, enabling, clinical problem solving, teamwork, and leadership. Each of these domains is comprised of between two and seven competency standards. Each standard is further divided into component parts or 'elements' and the elements are illustrated with performance criteria. The competency standards are currently being used in several Australian critical care educational programmes and are the foundation for an emerging critical care credentialling process. They have been viewed with interest by a variety of non-critical care specialty groups and may form a common precursor from which further specialist nursing practice assessment will evolve.

Educational Software For Teaching: Neuromonitoring In Anesthesia And Critical Care

NEURALIS is a specific interactive, multiple-choice educational software package for neuromonitoring in anesthesia and critical care. The system runs on Windows 95, 98 or NT 4.0. The system is based on a databank consisting of a presentatio n module and a question-answer module. Both components contain texts, diagrams a nd bit maps. The contents are organized in six categories for users to assess th eir knowledge. The question blocks contain a variable redundancy mechanism and t he individual questions can be configured in an increasing order or randomly. NEURALIS was evaluated by 108 participants at three international postgraduate workshops for neuromonitoring. On a scale of one to five (1 = excellent, 5 = poo r), the average score was 1.13. This indicates a very good acceptance of this ed ucational tool by users. INTRODUCTION The use of computer-assisted learning is increasing rapidly in undergraduate and postgraduate medical education. NEURALIS, developed in 1995 and updated regularly, is one of the first comprehensive medical educational software packages. It was developed with a multiple-choice mode for postgraduate training in neuromonitoring in anesthesia and critical care and is also being used for training medical students. METHODS NEURALIS was developed with the CBT tool BD EXPERT to run on Windows 95, 98 or NT 4.0. The educational objectives are organized in blocks on electrophysiology in anesthesia and critical care, electroencephalogaphy, evoked potentials and technical and clinical methods. With automatic statistical evaluation, both the student and the teacher can evaluate the answers to individual questions as well as knowledge in the different subject blocks. Then a training program can be planned. In the question module the user can chose an adaptable redundancy mechanism and an increasingly consistent question mechanism as well as a subject-oriented or random query mode. The answer module contains a correct-incorrect evaluation as well as an evaluation compartment. The system can be expanded with animations and video clips. To evaluate the acceptance of NEURALIS as a postgraduate teaching tool, the system was evaluated by 108 anesthesiologists, critical care specialists and biomedical engineers on a five point scale (1 = excellent, 2 = good, 3 = satisfactory, 4 = fair, 5 = poor). RESULTS The following figures are examples from the question – answer module from different subject groups. Fig 1 a,b – 4 a,b: NEURALIS-examples. Educational Software For Teaching: Neuromonitoring In Anesthesia And Critical Care

Position statement on postgraduate critical care nursing education – October 1999

The Australian College of Critical Care Nurses Limited (ACCCN) (formerly the Confederation of Australian Critical Care Nurses (CACCN)) considers appropriate preparation of specialist critical care nurses a vital component for the provision of quality care to patients and their families. The following discussion paper provides the recommendations of ACCCN regarding postgraduate critical care nursing education. Where possible, these recommendations are based on evidence from research in critical care nursing and allied fields. In areas in which current research-based evidence is not available, these recommendations are based on the opinion of expert nurses in the field of critical care nursing in Australia.

Stress ulcer prophylaxis in an evidence-based analysis of therapy.

Abstract The American Society of Health-System Pharmacists (ASHP) therapeutic guidelines on stress ulcer prophylaxis are the first society-based published guidelines. These guidelines were promulgated following a rigorous and formal examination of the published medical literature. This evidence-based medicine approach is crucial for the development of comprehensive scientifically based clinical care. A multidisciplinary team including pharmacy specialists in critical care and drug information, consulting physicians and nurses, and an independent panel of clinical specialists appointed by ASHP prepared and reviewed the guidelines. The guidelines can aid health care professionals in identifying appropriate patients for stress ulcer prophylaxis and selecting cost-effective therapeutic options. The scope of the article includes application of guidelines for patients of all ages following a stressful event, such as trauma or surgery, which would predispose them to stress-induced bleeding. Therapeutic agents evaluated include only those available in the United States, regardless of United States Food and Drug Administration-approved labeling. The article is divided into sections with pertinent issues related to stress ulcer prophylaxis in adults and pediatrics, when plausible. The evidence-based medical guidelines were developed following a comprehensive literature review of each presented issue. Summary data from randomized controlled trials and meta-analyses are presented to validate and strengthen the authors' line of reasoning. A summary and recommendation paragraph follows each major section. The first section evaluates the issues of frequency of bleeding, efficacy of prophylaxis, and risk factors for bleeding in general. The second major area of review includes these same topics as they relate to special populations. Other topics evaluated include the efficacy of prophylactic agents on bleeding prevention and mortality. A separate part evaluates the frequency of nosocomial pneumonia associated with stress ulcer prophylaxis. Therapeutic monitoring, other options for prophylaxis, prevention of recurrent bleeding, discontinuation of prophylaxis, and economic analysis complete the article.

Incorporating palliative care into critical care education: principles, challenges, and opportunities.

To identify the goals and methods for medical education about end-of-life care in the intensive care unit (ICU). A status report on palliative care, a summary report of recent research on palliative care education, articles in the medical literature on end-of-life care and critical care, and expert opinion were considered. A working group, including specialists in critical care, palliative care, medical ethics, consumer advocacy, and communications, was convened at the "Medical Education for Care Near the End of Life National Consensus Conference." A modified nominal group process was used to develop a consensus. In the ICU, life and death decisions are often made in a crisis mode or in the face of uncertainty, and may necessitate the withholding and withdrawal of life-supporting technologies. Because critical illness often diminishes the capacity of patients to make decisions, clinicians must often make decisions in conjunction with surrogates, rather than with patients. Discontinuity of care can threaten trusting relationships, and cultural diversity can have a particularly powerful impact on choices for care. In the face of these realities, it is possible and appropriate to give compassionate palliative care to dying patients and their families in the ICU. Teaching care of the dying in the ICU should emphasize the following: a) the goals of care should guide the use of technology; b) understanding of prognostication and treatment withholding and withdrawal is essential; c) effective communication and trusting relationships are crucial to good care; d) cultural differences should be acknowledged and respected; and e) the delivery of excellent palliative care is appropriate and necessary when patients die in the ICU.

Systematic Transesophageal Echocardiographic Examination in Mitral Valve Repair

Systematic Transesophageal Echocardiographic Examination in Mitral Valve Repair

Defining surgical critical care as an integrated specialty

PurposeAmong general surgeons, resistance to incorporating critical care specialists into the mainstream of surgical critical care is well documented. Loss of control, fragmentation of care, added cost, and the abdication of expertise are frequently cited as objections to this approach. In 1992, we began to explore the feasibility of developing a fully integrated, multidisciplinary surgical critical care program, structured to avoid these pitfalls. The conversion from a traditional nonintegrated surgical model was completed in 1993. This report summarizes the structural changes and results of this effort. MethodsThe Surgical Critical Care Service was converted from a combined trauma/critical care service into a multidisciplinary section of the Department of Surgery, composed of 12 full-time faculty (7 surgeons, 5 nonsurgeons). All (surgeons and nonsurgeons) are active full-time members of the department with a director (nonsurgeon) and a residency program director (surgeon) who report to the chairman of the department. Patient care is both vertically (surgical team) and horizontally (intensive-care-unit team) integrated with a surgical/critical care resident functioning as the key crossover member of both teams. Educational programs are organized and administered by the residency program director with faculty choice based on ability rather than training background. A work group composed of the chairman, key section directors (anesthesiology, critical care, trauma, burns, and cardiac surgery), and the assistant vice president of nursing meet monthly to provide global direction and resolve differences of opinion. ResultsTension between general surgeons and critical care specialists has been eliminated. Objective performance parameters have significantly improved since the conversion. Resident evaluations and American Board of Surgery In-Service Training Examination (ABSITE) performance remained constant or improved after conversion. ConclusionThe development of a multidisciplinary critical care program based in the Department of Surgery relieves professional tensions, improves the quality of care, and enhances educational and research opportunities for both critical care and general surgery residents.

Rural people's experience of critical illness involving inter-hospital transportation: a qualitative study

In recent years there has been a growing awareness of the problems people living in rural areas of Australia face in accessing health-care services. In particular, those experiencing a critical illness or major trauma and requiring specialist critical care services, often available only in metropolitan areas, may require inter-hospital transportation, usually by air ambulance. Management of such patients aims at achieving physiological stabilisation, organising the transfer and communicating with the transport team. As critical care nurses espouse a holistic approach to care, it is imperative that nursing practice aim to meet all the needs of these people. Therefore, critical care nurses should be aware of what such patients are experiencing. A qualitative research study, using Heideggerian hermeneutic phenomenology, was undertaken to explore the experiences of a group of people from rural NSW with a critical illness that necessitated their transfer by air ambulance to a metropolitan critical care unit for further management. Data analysis from interviews with the study participants revealed four major themes. This paper discusses the findings from one such theme, the impact of inter-hospital transportation, and highlights the anxiety and confusion experienced by rural people transferred to a metropolitan critical care unit. Recommendations for nursing care that minimises this anxiety and confusion are discussed.

A 60-Year-Old Woman with Weakness, Fatigue, and Acute Respiratory Failure: Case Report and Discussion of the Differential Diagnosis

A 60-year-old woman with chronic progressive fatigue, diurnal somnolence, proximal muscle weakness, and dyspnea developed acute respiratory failure when given supplemental oxygen. Hypoventilation secondary to neuromuscular dysfunction was suspected by the critical care specialist. Neurologic consultation and supportive laboratory evaluations led to the diagnosis of acid maltase deficiency, which was confirmed by muscle biopsy. The discussion includes a literature review that describes the pathophysiology and treatment of this rare muscle enzyme deficiency disorder. Acid maltase deficiency should be suspected in any adult presenting with hypoxemia, fatigue, and acute respiratory failure.

Pediatric death certification.

To determine location, manner, and physician certifier of pediatric deaths. A descriptive study of death certificate information for all child deaths (aged birth through 17 years) for the years 1995 and 1996. Urban county of more than 780,000 population. Field of specialty of physician certifiers, location of death, and category of deaths certified by the medical examiner. Of 361 child deaths, 42.6% were certified by the medical examiner, 24.1% by neonatologists, 10.0% by obstetricians, 8.0% by pediatric critical care specialists, and 5.3% by general pediatricians. The remaining deaths were certified by pediatric subspecialists, surgeons, family practitioners, emergency medicine specialists, hospital pathologists, and law enforcement officials. The medical examiner certified deaths due to trauma (64.5%), sudden infant death syndrome (13.5%), unexplained or suspicious causes (9.7%), medical or surgical complications (3.9%), or because no other physician certifier was available (5.8%). Most children were pronounced dead at hospitals, but 10.0% died at home, 4.4% on roads, and 2.5% on public or private lands. General pediatricians are unlikely to be directly involved in the care of most children who die and are therefore unlikely to sign the death certificate. Education about death and dying issues should be available for all pediatricians but should be directed at those specialists most likely to provide care during critical events. Support services for families need to be community based and accessible to survivors.

Fiberoptic Endoscopy and the Difficult Airway, 2nd edition

Assistant Professor, Department of Anesthesiology, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27157–1009 tharwood@bgsm.edu.James C. Eisenach, M.D., Editor.Fiberoptic Endoscopy and the Difficult Airway, 2nd edition. By Andranik Ovassapian. Philadelphia, Lippincott-Raven, 1996. Pages: 304. Price:$135.00.Andranik Ovassapian's Fiberoptic Endoscopy and the Difficult Airway is a revised and augmented edition of his 1990 Fiberoptic Endoscopy in Anesthesia and Critical Care. The targeted audience includes anesthesiologists, emergency medicine physicians, critical care specialists, otolaryngologists, and trauma surgeons. I believe the information presented in the book is of great benefit to its intended audience.Of the 15 chapters, 5 are new and 8 are rewritten. The publication makes excellent use of graphics that impart the message more effectively than text can. Numerous black and white drawings are accompanied by high quality color photographs that picture the various anatomic and technologic aspects of this subject. The writing is concise with little of the extraneous text or redundancy found in some textbooks written by multiple authors. The index is detailed enough to provide ease of finding specific topics.The outline of the book progresses logically, starting with the basics of the fiberoptic scope, the pertinent anatomy and physiology, and radiologic assessment of the airway. Preparation of the patient's airway with topical anesthesia is then thoroughly discussed. This discussion is essential and extremely helpful, considering the greater efficiency with which fiberoptic endoscopy is performed after proper airway preparation. Likewise, Dr. Ovassapian discusses the various techniques of airway anesthesia and their relative benefits and drawbacks.Much of the chapter on conscious sedation is a primary text discussing the general subject and is not well designed as a discussion of sedation specifically for fiberoptic endoscopy. For example, although the use of propofol, midazolam, and fentanyl are well discussed, some other pharmacologic agents that clinicians may find helpful are not (e.g., ketamine, droperidol). Following are chapters dealing with various aspects of the topic such as the adult, obstetric, and pediatric airways, bronchial endoscopic techniques, and critical care endoscopy. Important clinical teaching gems that are often overlooked by practitioners (e.g., “this [jaw thrust] maneuver is vital, constituting the most important step in fiberoptic intubation under anesthesia.”) are included throughout these chapters. Subsequent chapters deal with the difficult airway, with updated areas such as endoscopy using the laryngeal mask airway (LMA) and esophageal airways. Although the LMA is given a specific chapter (which is good), the previous chapter dealing with management of the difficult airway mentions the LMA sparingly, and because the textbook was published in 1996, the older (1993) ASA algorithm, which does not incorporate the LMA, is displayed.In addition, extubation of the difficult airway, an area relatively unexamined by other writers, is given careful and detailed commentary. Dr. Ovassapian concludes his book by demonstrating his competency as a teacher with the chapter “Learning Fiberoptic Intubation Techniques.” Even the most inexperienced practitioner, after reading this chapter and using some guided instruction, should be able to perform airway endoscopy with greater confidence.In summary, Dr. Ovassapian's new textbook is a valuable addition worth its price to any operating room or intensive care unit bookshelf because of its unique and well-constructed content. It is not without significance that the “A” in ABC (airway, breathing, circulation) comes first. When confronted by the rare difficult or compromised airway, it is of critical importance that the clinicians be as well educated as possible in the evaluation and management of this subject.Timothy N. Harwood, M.D.Assistant Professor; Department of Anesthesiology; Bowman Gray School of Medicine; Winston-Salem, North Carolina 27157–1009tharwood@bgsm.edu

The role of the nephrologist in the intensive care unit.

advances in medicine and surgery permitting treatment Intensive care units were created to provide specialized of severe disorders. Consequently, the demand for nursing care and monitoring in a consolidated area. intensive care beds has resulted in the spawning of Over time, physicians with critical care expertise have intensive care units (ICU ) and training programs for become increasingly available. The organization of the critical care medicine and critical care nursing. medical staff in the ICU should facilitate exemplary These new trends have induced numerous problems patient care in the most effective and cost-efficient in the organization of the ICU and have brought into manner possible. question the precise role of the critical care specialist Most institutions have developed critical care units or ‘intensivist’. In some ICUs, the role of the nephrolowith either an ‘open’ or a ‘closed’ organizational model. gist, as well as that of other specialists who had In the open system, patients are admitted to the ICU traditionally occupied a prominent place in this setting, under the care of a personal physician. In many open is challenged by the intensivist. When it is difficult to ICUs, critical care specialists are available to provide find a gentleman’s agreement between the parties, expertise via consultation. In the closed system, hospital administrations and certifying and credenpatients requiring ICU admission are transferred to tialling organizations can dictate medical practice in a the care of a critical care specialist or team and an way that conflicts with the patient’s best interests. intensivist may treat patients with acute renal failure Since two-thirds of critically ill patients with ARF without the participation of a nephrologist. requiring dialysis die in hospital [3], it is appropriate Moment to moment monitoring and care are the to question whether they received the most appropriate hallmarks of the closed system. In open models, there care in the most appropriate unit. are often separate specialty ICUs with a specialist from

Focus of nursing in critical and acute care settings: prevention or cure?

The fluidity of the boundaries of critical and acute care can lead to challenges for nurses working on acute general wards when caring for post-critical care patients and for those in whom a critical care situation arises during a period of acute care. The development and use of critical care skills pose special difficulties for acute care nurses, because of the acuteness and infrequency of such incidents and the diversity of skills the nurses need to possess. Nonetheless, critical care is an important component of an acute ward nurse's repertoire, particularly in relation to preventing episodes of critical illness. It might be expected that the increased provision of high dependency units and the formation of postoperative care teams would relieve some of this pressure, but such developments are, in fact, more likely to create an increase in overall patient acuity. They may, in addition, lead to an over-reliance on the use of such facilities and must be implemented carefully in order to bridge, rather than widen, the gap between acute and critical care. Critical care is used in this paper as a global term, to encompass all settings where patients are usually more highly dependent and critically ill than patients on general wards. It includes intensive therapy, high-dependency, coronary care and other specialist critical care units.

Percutaneous dilational tracheostomy: anesthetic considerations for a growing trend.

Percutaneous dilational tracheostomy (PDT) is a new technique for the establishment of prolonged mechanical ventilation in the critical care setting. Critical care specialists who perform PDTs consult anesthesiologists to provide airway support as well as sedation for these procedures. The purpose of this review is to introduce the principles, complications, and advantages of percutaneous tracheostomy. Airway and anesthetic considerations for this procedure are examined. PDT is a natural extension of the current surgical trend toward minimally invasive procedures. The technique was first described by Ciaglia et al. (1) in 1985 as an alternative to standard tracheostomy. Interest in the technique has grown with the publication of results and long-term follow-up by the same group in 1992 (2). The perceived advantages over standard surgical tracheostomy include its speed, simplicity, and low reported incidence of complications. PDTs are performed in the intensive care unit (ICU) by critical care specialists, including surgeons, anesthesiologists, and pulmonary care intensivists. PDT is amenable to bedside insertion, eliminating the risks and resources involved in the transportation of the critically ill patient. Since operating room time is unnecessary, substantial cost savings can also be expected.

Effects of Organizational Change in the Medical Intensive Care Unit of a Teaching Hospital

To compare the effects of change from an open to a closed intensive care unit (ICU) format on clinical outcomes, resource utilization, teaching, and perceptions regarding quality of care. Prospective cohort study; prospective economic evaluation. Medical ICU at a university-based tertiary care center. For the open ICU, primary admitting physicians direct care of patients with input from critical care specialists via consultation. For the closed ICU, critical care specialists direct patient care. Consecutive samples of 124 patients admitted under an open ICU format and 121 patients admitted after changing to a closed ICU format. Readmissions were excluded. Comparison of hospital mortality with mortality predicted by the Acute Physiology and Chronic Health Evaluation II (APACHE II) system; duration of mechanical ventilation; length of stay; patient charges for radiology, laboratory, and pharmacy departments; vascular catheter use; number of interruptions of formal teaching rounds; and perceptions of patients, families, physicians, and nurses regarding quality of care and ICU function. Mean +/- SD APACHE II scores were 15.4 +/- 8.3 in the open ICU and 20.6 +/- 8.6 in the closed ICU (P=.001). In the closed ICU, the ratio of actual mortality (31.4 percent) to predicted mortality (40.1 percent) was 0.78. In the open ICU, the ratio of actual mortality (22.6 percent) to predicted mortality (25.2 percent) was 0.90. Mean length of stay for survivors in the open ICU was 3.9 days, and mean length of stay for survivors in the closed ICU was 3.7 days (P=.79). There were no significant differences between periods in patient charges for radiology, laboratory, or pharmacy resources. Nurses were more likely to say that they were very confident in the clinical judgment of the physician primarily responsible for patient care in the closed ICU compared with the open ICU (41 percent vs 7 percent; P<.Ol), and nurses were the group most supportive of changing to a closed ICU format before and after the study. Based on comparison of actual to predicted mortality, changing from an open to a closed ICU format improved clinical outcome. Although patients in the closed ICU had greater severity of illness, resource utilization did not increase.

Predicting death after CPR experience at a nonteaching community hospital with a full-time critical care staff: Chest 1995; 108/4 (1009–1017)

Objective To identify a series of variables which predict death after in-hospital cardiopulmonary resuscitation (CPR). Design Retrospective observational study. Setting A nonteaching community hospital with 24-hr on-site critical care specialists. Patients Consecutive adults undergoing CPR between August 1989 and July 1991. Intervention: None . Measurements and main results Two hundred forty-two patients suffered a total of 289 cardiopulmonary arrests. Forty patients (16.5%) survived to discharge. Thirty-nine (16%) patients had more than one cardiopulmonary arrest. Survival of second CPR was 18%. Acute physiology and chronic health evaluation (APACHE) II scores within 24 h of admission and CPR (APACHE [a] and APACHE [b]) were measured. APACHE (a) and (b) scores more than 20 had a 96% predictive value positive and were associated with a five-fold decrease in survival. Besides APACHE, cardiopulmonary arrests on medical floors and after day 4 of hospitalization, duration of CPR more than 15 min, and asystole assumed significance at multivariate levels for predicting death. Ventilatory assistance and Glasgow coma score of less than 9 at 24 h after CPR predicted death for initial survivors at multivariate levels. Survival on telemetry units were similar to the ICU (17 vs 21%) but twice that of the medical floors. Conclusion The CPR outcome can be predicted early during hospital course, which may assist physicians to formulate a do-not-resuscitate order. Patients surviving a CPR should be considered candidates for another resuscitation if clinically warranted. Low-risk patients can safely be admitted to telemetry units instead of to more costly ICUs.

ETHICS CONSULTATION

This article comprehensively addresses the composition, role, and functions of a hospital ethics committee (HEC). HECs are of particular interest to critical care specialists because they often participate in or lead such committees, extending their commitment to communication and caring beyond the borders of the intensive care unit (ICU). This article also demonstrates that a well-run ICU in a hospital with a strong HEC automatically will include many of the services that the HEC normally would provide, without the need for HEC assistance.

Predicting Death After CPR: Experience at a Nonteaching Community Hospital with a Full-time Critical Care Staff

To identify a series of variables which predict death after in-hospital cardiopulmonary resuscitation (CPR). Retrospective observational study. A nonteaching community hospital with 24-hr on-site critical care specialists. Consecutive adults undergoing CPR between August 1989 and July 1991. None. Two hundred forty-two patients suffered a total of 289 cardiopulmonary arrests. Forty patients (16.5%) survived to discharge. Thirty-nine (16%) patients had more than one cardiopulmonary arrest. Survival of second CPR was 18%. Acute physiology and chronic health evaluation (APACHE) II scores within 24 h of admission and CPR (APACHE[a] and APACHE[b]) were measured. APACHE(a) and (b) scores more than 20 had a 96% predictive value positive and were associated with a five-fold decrease in survival. Besides APACHE, cardiopulmonary arrests on medical floors and after day 4 of hospitalization, duration of CPR more than 15 min, and asystole assumed significance at multivariate levels for predicting death. Ventilatory assistance and Glasgow coma score of less than 9 at 24 h after CPR predicted death for initial survivors at multivariate levels. Survival on telemetry units were similar to the ICU (17 vs 21%) but twice that of the medical floors. The CPR outcome can be predicted early during hospital course, which may assist physicians to formulate a do-not-resuscitate order. Patients surviving a CPR should be considered candidates for another resuscitation if clinically warranted. Low-risk patients can safely be admitted to telemetry units instead of to more costly ICUs.

Clinical Pulmonary Medicine

<i>Clinical Pulmonary Medicine</i>, a journal for both pulmonologists in clinical practice and critical care specialists, was created to provide concise and easy-to-read review articles encompassing recent advances in pulmonary medicine. The bimonthly issues include one or occasionally two review articles in each of seven subspecialty areas: obstructive airway disease; respiratory infections; interstitial, inflammatory, and occupational diseases; clinical practice management; critical care; and two more general departments, "Colleagues in Respiratory Medicine" and "Topics in Pulmonary Medicine." Each issue also includes summaries and commentary on three or four recent articles from other clinical journals. This format, if it can be maintained, promises to provide a comprehensive but focused educational tool for keeping practitioners current on major developments affecting pulmonary practice. The editorial board, led by editor-in-chief Michael S. Niederman, includes an elite group of US clinical practitioners, representing a cross-section of major academic medical centers. The review articles themselves are solicited by