Critical Care Specialists Research Articles

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

The present and future of cardiac arrest care: international experts reach out to caregivers and healthcare authorities.

The purpose of this review is to describe the epidemiology of out-of-hospital cardiac arrest (OHCA), disparities in organisation and outcome, recent advances in treatment and ongoing controversies. We also outline the standard of care that should be provided by the critical care specialist and propose future directions for cardiac arrest research. Narrative review with contributions from international resuscitation experts. Although it is recognised that survival rates from OHCA are increasing there is considerable scope for improvement and many countries have implemented national strategies in an attempt to achieve this goal. More resources are required to enable high-quality randomised trials in resuscitation. Increasing international collaboration should facilitate resuscitation research and knowledge translation. The International Liaison Committee on Resuscitation (ILCOR) has adopted a continuous evidence review process, which facilitate the implementation of resuscitation interventions proven to improve patient outcomes.

Abstract P-143: RISK STRATIFICATION OF CRITICALLY ILL CHILDREN AND NEONATES WITH ACUTE GENERAL SURGICAL PATHOLOGY REQUIRING STABILISATION, TRANSFER TO TERTIARY CARE FACILITY AND FACTORS PREDICTING MORTALITY

Aims & Objectives: Aim of this study is to evaluate the factors which predict mortality in patients who present to secondary care hospitals with acute surgical problems requiring transfer to tertiary care facility. The risk stratification will help acute care transfer teams to organize transport of these children more effectively, which would further help in reducing the mortality. Methods Paediatric critical care transfer referrals to North West & North Wales Transport Services in UK over the last 5 years were selected. The data is collected from the case notes which were recorded by the acute care transfer team, from the time the patient was first referred to the team by phone till 24 hours post transfer. Results During the study period there were 181 patients presented to district general hospitals in this region of UK with acute surgical problems and required critical care advice or transfer to higher centres. Preterm and Neonatal age group predominate among the study population (94/181=52%). Among the 181 patients, 170 patients required transferred to higher centre either for specialist opinion, surgery and/or critical care. There were 7 deaths during the study period, mortality being 7/181=3.9%. Lactate level >5, suspected sepsis, and haematological abnormality were strongly associated with mortality in our study population. 25 patients were transferred by local team with available medical personnel as time critical transfer based on the underlying condition. Conclusions High lactate is the most important single predictor in acute surgical paediatric patients who will require time critical transfer and also an important predictor of mortality.

Paediatric critical care needs assessment in a tertiary facility in a developing country

Introduction and Aim: There is a great burden of critically ill children in developing countries where paediatric critical care is still in its early stages. The actual burden of critically ill children is necessary for healthcare planning however, in Nigeria the magnitude is unknown. In order to provide the basic paediatric intensive care services which will likely reduce mortality and improve patient outcomes, the specific burden and need for various aspects of paediatric critical care services must be quantified. This study set out to determine the volume, specific critical care needs and outcomes of critically ill paediatric emergencies in the UCH.Methods: It was a prospective study of all consecutive patients admitted into the children’s emergency ward over a three-month period. Data on clinical state on admission and the need or otherwise for critical care using the paediatric assessment triangle (PAT) were documented.Results: There were 391 admissions during the study period, of which 130 were critically ill. They had one or more of the following; respiratory distress 93(28.3%), respiratory failure 35 (19.0%), shock 65(50%), central nervous system/metabolic derangements 64 (49.2%). Eighty-nine (68.5%) of the critically ill were under-5s. The diagnoses commonly associated with critical illness were malaria, 59 (45.4%), septicaemia, 18, (13.8%) and meningitis 17 (13. 1%). Four of the critically ill children (2.8%) were admitted into the general ICU and 33 (25.4%) died within 48hours of presentation.Conclusion: There is a huge burden of critical care needs among children presenting to the children’s emergency ward, which remains largely unmet. There is an urgent need to address paediatric critical care services in order to improve child survival.

Management of Acute Liver Failure: A Pediatric Perspective.

Purpose of ReviewPediatric acute liver failure is a rare, complex, rapidly progressing, and life-threatening illness. Majority of pediatric acute liver failures have unknown etiology. This review intends to discuss the current literature on the challenging aspects of management of acute liver failure.Recent FindingsCollaborative multidisciplinary approach for management of patients with pediatric acute liver failure with upfront involvement of transplant hepatologist and critical care specialists can improve outcomes of this fatal disease. Extensive but systematic diagnostic evaluation can help to identify etiology and guide management. Early referral to a transplant center with prompt liver transplant, if indicated, can lead to improved survival in these patients.SummaryPrompt identification and aggressive management of pediatric acute liver failure and related comorbidities can lead to increased transplant-free survival and improved post-transplant outcomes, thus decreasing mortality and morbidity associated with this potential fatal condition.

Survey of veterinary specialists regarding their knowledge of radiation safety and the availability of radiation safety training.

OBJECTIVE To evaluate the knowledge of various veterinary specialists regarding various radiation safety matters and determine the availability of radiation safety training. DESIGN Cross-sectional study. SAMPLE 164 radiology, 81 internal medicine, and 108 emergency and critical care (ECC) specialists. PROCEDURES An online survey was developed regarding knowledge of and training in radiation safety, and invitations were sent via email through the email lists of the veterinary internal medicine, ECC, and radiology specialty colleges. Responses were summarized, and comparisons were made between radiologists and internal medicine and ECC clinicians. RESULTS 65.5% (38 /58) of respondents from academic institutions and 30.0% (33/110) of respondents from private practices indicated that radiation safety training was mandatory at their institution for personnel who work with ionizing radiation-emitting equipment, and 80.2% (85/106) and 56.6% (77/136), respectively, had received some radiation safety training. Low proportions of radiologists and internal medicine and ECC clinicians correctly identified the effective dose of ionizing radiation associated with 3-phase esophagography and 3-phase abdominal CT. Many radiologists (92/153 [60.1%]) and nonradiologists (92/179 [51.4%]) believed that the effective doses used in veterinary practice pose no increased risk of fatal cancer to their patients. CONCLUSIONS AND CLINICAL RELEVANCE Radiation safety training, although more common in academia, was not universally available and may not meet radiography equipment license requirements for some institutions. Most radiologists, internal medicine clinicians, and ECC clinicians had a poor understanding of the amount of ionizing radiation associated with medical imaging procedures and the potential hazards to their patients.

Acute respiratory diseases in pregnancy

Pregnant women are known to have an increased morbidity and mortality for certain illnesses due to physiological and immunological changes in pregnancy. However, careful attention should be paid to the fetoplacental unit, with delivery generally indicated for obstetric purposes only. Acute respiratory distress syndrome is an uncommon condition in pregnant patients. An essential component in the management of this condition is a perfect coordination between the obstetrician, the pneumologist and critical care specialists. Pregnancy-associated venous thromboembolism consists of deep vein thrombosis and pulmonary embolism occurring during pregnancy or in the postpartum period. This condition is common and is a major source of morbidity in a population which is young and otherwise relatively healthy. Amniotic fluid embolism remains one of the most devastating conditions in obstetrics practice, with reported mortality of 20% to 60%. The treatment is mainly supportive and involves the delivery of the fetus when indicated, respiratory support and hemodynamic support, with the judicious use of fluids, vasopressors, inotropes and, in some cases, pulmonary vasodilators. Respiratory failure complicates a relatively small number of pregnancies, but carries significant potential risks for both mother and fetus. The causes of respiratory failure may be related to pregnancy-specific conditions or other respiratory diseases, and the management requires a multidisciplinary team approach, involving obstetrics, maternal-fetal medicine, neonatology, obstetric medicine, pulmonology and critical care.

Translation and cross-cultural adaptation of the Pediatric Confusion Assessment Method for the Intensive Care Unit into Brazilian Portuguese for the detection of delirium in pediatric intensive care units.

ObjectiveTo undertake the translation and cross-cultural adaption into Brazilian Portuguese of the Pediatric Confusion Assessment Method for the Intensive Care Unit for the detection of delirium in pediatric intensive care units, including the algorithm and instructions.MethodsA universalist approach for the translation and cross-cultural adaptation of health measurement instruments was used. A group of pediatric critical care specialists assessed conceptual and item equivalences. Semantic equivalence was evaluated by means of a translation from English to Portuguese by two independent translators; reconciliation into a single version; back-translation by a native English speaker; and consensus among six experts with respect to language and content understanding by means of Likert scale responses and the Content Validity Index. Finally, operational equivalence was assessed by applying a pre-test to 30 patients.ResultsThe back-translation was approved by the original authors. The medians of the expert consensus responses varied between good and excellent, except for the feature "acute onset" of the instructions. Items with a low Content Validity Index for the features "acute onset" and "disorganized thinking" were adapted. In the pre-test, the expression "signal with your head" was modified into "nod your head" for better understanding. No further adjustments were necessary, resulting in the final version for Brazilian Portuguese.ConclusionThe Brazilian version of the Pediatric Confusion Assessment Method for the Intensive Care Unit was generated in agreement with the international recommendations and can be used in Brazil for the diagnosis of delirium in critically ill children 5 years of age or above and with no developmental cognitive disabilities.

Organ Donor Management: Part 1. Toward a Consensus to Guide Anesthesia Services During Donation After Brain Death.

Worldwide 715 482 patients have received a lifesaving organ transplant since 1988. During this time, there have been advances in donor management and in the perioperative care of the organ transplant recipient, resulting in marked improvements in long-term survival. Although the number of organs recovered has increased year after year, a greater demand has produced a critical organ shortage. The majority of organs are from deceased donors; however, some are not suitable for transplantation. Some of this loss is due to management of the donor. Improved donor care may increase the number of available organs and help close the existing gap in supply and demand. In order to address this concern, The Organ Donation and Transplantation Alliance, the Association of Organ Procurement Organizations, and the Transplant and Critical Care Committees of the American Society of Anesthesiologists have formulated evidence-based guidelines, which include a call for greater involvement and oversight by anesthesiologists and critical care specialists, as well as uniform reporting of data during organ procurement and recovery.

Prognosis and treatment of FOLFOX therapy related interstitial pneumonia: a plea for multimodal immune modulating therapy in the respiratory insufficient patient

BackgroundThe FOLFOX regimen, i.e., folinic acid (FOL), fluorouracil (F) and oxaliplatin (OX), is a drug cocktail that is used to treat gastric and colorectal cancers. Despite the concomitant improvements in response rate, duration of response and patient survival, reports of serious toxic pulmonary side effects have progressively emerged.Case presentationWe describe a patient who was treated with FOLFOX as an adjuvant to a rectosigmoidal resection of a rectosigmoidal carcinoma and who developed respiratory insufficiency requiring mechanical ventilation. Computed tomography (CT) imaging and open lung biopsy findings were compatible with interstitial pneumonia (IP). She received multimodal combination treatment (acetylcysteine, corticosteroids, immune globulins and cyclophosphamide) and survived.We performed a systematic literature search and reviewed all 45 reported cases of FOLFOX-related lung toxicity and/or pulmonary fibrosis for their clinical characteristics and their outcomes related to therapy.ConclusionsWe found that for the 45 cases with available data, the median age was 70 years, and the male–female ratio was 3.5: 1. In the patients exhibiting only mild respiratory symptoms, discontinuation of the culprit drug (oxaliplatin) resulted in a 100% regression of the symptoms. However the prognosis of the respiratory insufficient patient proved to be grim: death occurred in 76.9% of the cases despite conventional treatment with corticosteroids. We therefore urge oncologists and critical care specialists not to limit their interventions to the discontinuation of chemotherapy, artificial ventilation, corticosteroids and glutathione replenishment and to consider the gradual introduction of additional immune-modulating agents whenever life-threatening respiratory symptoms in oxaliplatin-treated patients do not subside; all the more so considering the fact that our analysis showed that every patient who survived intubation and mechanical ventilation experienced a full clinical recovery.

Protocol-Directed Sedation Versus Non-Protocol-Directed Sedation to Reduce the Duration of Mechanical Ventilation in Intensive Care Patients.

Protocol-Directed Sedation Versus Non-Protocol-Directed Sedation to Reduce the Duration of Mechanical Ventilation in Intensive Care Patients.

Observational studies help us understand how to treat pandemic influenza and other emerging virus diseases

In his editorial, Zhang (1) comments on my earlier article that suggested inexpensive and widely available generic drugs might be used to reduce mortality from pandemic influenza, Ebola and other emerging virus diseases (2). He notes that several earlier studies explored the possibility that statins might be used to treat patients with sepsis and acute respiratory distress syndrome (ARDS) (1). Many individual observational studies [for example, (3)] and their meta-analyses (4) have suggested that statins might be effective in these patients, but several randomized controlled trials (RCTs) have failed to demonstrate their efficacy (5,6). Critical care specialists, many of them involved in these RCTs, have expressed different opinions on whether statins should still be considered potentially useful (7-9). In my view, the question is still open; the RCTs were conducted in mechanically ventilated ICU patients, and many of these patients were started on treatment late in the course of illness. Thus, statin treatment by itself may have been “too little, too late”. Nonetheless, the experimental and clinical rationale for this general approach to treating the host response in patients with critical illness is still persuasive. For many reasons, it must be further explored (2).

Editorial introductions

Editorial introductions

Color and Power Doppler Sonography for Pneumothorax Detection.

The use of B- and M-mode sonography for detection of pneumothorax has been well described and studied. It is now widely incorporated by sonographers, emergency physicians, trauma surgeons, radiologists, and critical care specialists worldwide. Lung sonography can be performed rapidly at the bedside or in the prehospital setting. It is more sensitive, specific, and accurate than plain chest radiography. The use of color and power Doppler sonography as an adjunct to B- and M-mode imaging for detection of pneumothorax has been described in a small number of studies and case reports but is much less widely known or used. Color and power Doppler imaging may be used for confirmation of the presence or absence of lung sliding detected with B-mode sonography. In this article, we examine the physics behind Doppler sonography as it applies to the lung, technique, an actual case, and the past literature describing the use of color and power Doppler sonography for the detection of pneumothorax.

Maternal super obesity and risk for intensive care unit admission in the MFMU Cesarean Registry.

Obesity is a risk factor for intensive care unit (ICU) admission in nonpregnant populations. Less is known about maternal obesity and ICU admission risk. The objective of this study was to estimate the association between maternal obesity and ICU admission among women who delivered via cesarean section or vaginal birth after cesarean section (VBAC). This is a retrospective cohort analysis of women who delivered via VBAC or cesarean section in the Maternal-Fetal Medicine Unit (MFMU) Cesarean Registry. We defined exposure as body mass index (BMI) at delivery stratified as non-obese (BMI 18.5-29.9 kg/m2 ), class I or II obese (BMI 30-39.9 kg/m2 ), morbidly obese (BMI 40-49.9 kg/m2 ), and super obese (BMI ≥ 50 kg/m2 ). The primary outcome was ICU admission. Modified Poisson regression models estimated relative risk (RR) of ICU admission by obesity strata, after adjusting for confounders. Mediation analysis was used to estimate the proportion of ICU admission risk attributable specifically to obesity. We included 68 455 women; 40% non-obese, 46% class I or II obese, 12% morbidly obese, and 2% super obese. Super obese women were at higher risk for ICU admission compared with non-obese women (0.7 vs. 1.3%, adjusted RR 1.61; 95% CI 1.01-2.65), after adjusting for confounders. Among super obese women, medical comorbidities mediated 58% of ICU admission risk, suggesting that a significant proportion of ICU admission is driven by maternal obesity. Super obese women who deliver by cesarean section or VBAC are at increased risk of peripartum ICU admission. Obstetricians and critical care specialists should consider possible ICU admission during delivery planning.

Thomas L Petty

Thomas L Petty

Treatment of Pregnant Patients With Orthopaedic Trauma.

Fracture management in pregnant patients is challenging. Anatomic and physiologic changes in pregnancy increase the complexity of treatment. Maternal trauma increases the risk of fetal loss, preterm birth, placental abruption, cesarean delivery, and maternal death. Initial resuscitation and treatment in a facility equipped to handle the orthopaedic injury and preterm births are paramount. Pelvic and acetabular injuries are potentially life threatening. The benefits and risks of surgical treatment must be carefully considered. The risks posed by anesthetic agents, antibiotic agents, anticoagulant agents, and radiation exposure must be understood. Positioning of the patient can affect the viability of the fetus. If surgery is necessary, the left lateral decubitus position decreases fetal hypotension. A specialized team including an obstetrician, perinatologist, orthopaedic surgeon, general trauma surgeon, critical care specialist, emergency medicine specialist, anesthesiologist, radiologist, and nurse must collaborate to improve maternal and fetal outcomes.

Hearing voices: Comparing two methods for analysis of focus group data

AimThis paper compares two qualitative approaches used to thematically analyse data obtained from focus groups conducted with critical care nurses from Australia. BackgroundFocus groups are an effective mechanism to generate understanding and gain insight into the research participants' world. Traditional verbatim transcription of participants' recorded words necessitates significant investment of time and resources. An alternative approach under reported in the literature is to directly analyse the audio recordings. To identify the effectiveness of the audio recording only approach, the study aimed to independently compare two qualitative methods of data analysis, namely the traditional transcribed method with the audio recording method. MethodsThe study to revise the specialist critical care competency standards included focus groups conducted in each state in Australia (n=12) facilitated by experienced researchers. Two of the research team analysed transcribed focus group data and two team members were blinded to the transcription process and directly analysed audio recordings from the focus groups. A process of thematic analysis used independently by the two teams was used to identify themes. ResultsWhen the findings were compared, the themes generated using each technique were consistent and there were no different themes or subthemes identified. The two techniques appeared to be comparable. Overarching key themes were consistent with the approach. ConclusionThe direct analysis method appears to have advantages. It is cost effective, trustworthy and possibly a superior alternative when used with focus group data. However, the audio only method requires experienced researchers who understand the context and if combining the two approaches takes time to do.

Intensive care unit models: Do you want them to be open or closed? A critical review.

Intensive care is a specialized branch of medicine dealing with the diagnosis, management, and follow up of critically ill or critically injured patients. It requires input from other branches of medicine on various issues. A critical care specialist has expertise in managing such patients round the clock. Based on his freedom to take decisions in the intensive care unit (ICU), different types of ICUs - open, closed, or semi-closed - have been defined. There is no doubt that all critical patients should be evaluated by an intensivist. Therefore, it is argued that a closed ICU model would be the ideal model. However, this may not always be feasible and other models may be more useful in resource-limited countries. In this review, we compare the different formats of ICU functioning and their suitability in different hospitals.

Unusual complication of intercostal chest drainage insertion: Retained surgical blade in liver

Intercostal chest tube drainage or tube thoracostomy procedure is widely used by the medical, surgical and critical care specialists. Despite being relatively a minor procedure, devastating complications can occur owing to inadequate knowledge of thoracic anatomy, improper training and lack of experience. Iatrogenic or technical complications are however rare, but can often be life-threatening. Here, we are reporting a case of an accidentally retained surgical blade in the right lobe of liver during chest tube insertion for the management of post-traumatic right pneumothorax. To the best of our knowledge, this is the first ever case report of a retained surgical blade in the liver as a complication of tube thoracostomy procedure, which was later successfully removed using laparoscopy.