Critical Care Topics Research Articles

Key Topics in Critical Care, 2nd edn

T. M. Craft, J. P. Nolan and M. J. A. Parr Taylor & Francis Ltd BIOS Scientific Publishers , ISBN: 1859962297 , Price: £27.99, 334 pp. The second edition of Key Topics in Critical Care maintains the highest standard of the Key Topics series. Written and compiled by experienced Critical Care doctors working in the United Kingdom and Australia, this edition has been comprehensively updated, with the inclusion of several current topics and contributions by new authors. Key Topics in Critical Care does not pretend to be a definitive text but provides balanced and concise detail on over 80 Critical Care topics, ranging from staffing and admission criteria to mechanical ventilation of a severe asthmatic. Essential information is clearly presented as readable short paragraphs and bullet points; each topic is completed with references to keynote papers, review articles or websites for further reading. Complicated subjects, such as liver failure, are clearly defined and divided into easily digestible subheadings, with relevant evidence-based guidelines for each topic. It is a pleasure to dip into this book, to renew or acquire facts, for interest, teaching or between clinical cases. Trainees from anaesthesia, medicine and surgery in particular will find this book invaluable for exam revision as Critical Care forms an important part of the examination syllabus. Post-fellowship and Advanced trainees in Critical Care will also value the book for fast access to clinical guidelines and as an aide-memoire to diverse topics. In the current era of evidence-based medicine, this book presents a valuable and informative basis to current thinking and practice. We would recommend this book to all trainees involved in Critical Care.

Pediatric Anesthesia: The Requisites in Anesthesiology.

Pediatric Anesthesia: The Requisites in Anesthesiology.

Jeff Mann's EM Guidemaps

Dr Mann's website is a clinically oriented resource targeted at emergency medicine physicians, intensivists, hospitalists and any other physicians who provide acute care. It might also be helpful for physicians in training. The website is plain and uncomplicated, allowing quick and easy access to very practical information regarding various clinical conditions. The guidelines are subdivided into the following: advanced cardiac life support, critical procedures, medical, obstetrical–gynecological, toxicology, trauma, and neuro-ophthalmology. Some examples under medical guidemaps are electrolyte abnormalities, gastrointestinal bleeding, diarrhea, and atrial fibrillation. There are many general topics that would be of interest to critical care physicians that are missing, such as shock, pneumonia, and respiratory failure. Information in each guideline is presented in point form, organized in sections. The hypokalemia guidemap, for example, has sections labeled 'introduction', 'risk factors', 'clinical presentation', and 'medical decision making and treatment'. The appendix includes information on electrocardiogram (ECG) changes and potential causes. The focus of each guidemap is on clinical diagnosis and treatment. Also included on the main page are chest pain tutorials including ECGs, and a 'soap box' section where many various emergency medicine and critical care topics are reviewed to various degrees. Each guidemap comes with its own URL, allowing each map to be saved as a favorite. The website is best viewed with Netscape browser, but we have had no difficulty viewing with Internet Explorer. All of the guidemaps are written by Dr Mann, and he provides a disclaimer that the guidemaps reflect his personal approach to problem solving and should not be regarded as a standard of care. It is not clear that the guidemaps are evidence based because the source of his information is not clear, and no references are provided. Dr Mann will not be adding further guidemaps but plans to revise them if they become outdated. However, no information regarding the date of the most recent update is provided.

Critical Care Assembly Critically Appraised Topics (CCCATS) Library

The Critical Care Assembly Critically Appraised Topics is a website that provides updates in relevant and controversial critical care topics using an evidence-based approach. In reviewing this site we browsed through the online offerings and assessed the information provided as well as the user interface. Each critically appraised topic (CAT) is structured so that the following information is included: the search strategy employed to identify significant trials in the area; a summary of each article identified, which includes a grading of the evidence, number of patients and major results; and short editorial comments. Each CAT is peer reviewed and updated as the literature warrants. The current library of CATs includes evidence-based reviews of 14 topics, including the following: weaning protocols; prone position in acute respiratory distress syndrome; vasopressin in septic shock; continuous renal replacement therapy in sepsis; thrombolytic therapy for acute pulmonary embolism (updated); glucose control in the critically ill; maximizing oxygen delivery in critically ill patients; and low tidal volume ventilation in acute respiratory distress syndrome. An example of the first topic is 'Noninvasive ventilation in hypoxemic respiratory failure'. According to the information provided on the website, PubMed and Uptodate were searched for articles published after 1990, using specific clinical queries such as 'noninvasive ventilation' and 'acute respiratory failure'. Seven trials were critically evaluated and their results summarized. Finally, the author of the CAT summarizes the study results and provided recommendations. This CAT was last updated in August 2001. This online resource is intended for intensivists and respiratory physicians devoted to critical care. It provides a brief summary of topics that are extremely important and helps intensivists to identify the most recent literature for each topic. Other positives include a direct link to PubMed, the abstract of each trial, and a brief summary of each trial including design and major results. In general, the conclusions of each of these reviews are reasonable and objective. Finally, there is an invitation for the public to submit CATs. There is unlimited access to the site, no particular browser or any special software is required, and it is easy to navigate. The owner is the American Thoracic Society – a reputable scientific society. Limitations of this site include the following. At present, there are only 14 CATs, most of which have been written by one individual. In addition, at the moment, only two topics have been updated. Finally, it would be helpful to include some CATs that are relevant to pediatrics.

International distance education and the transition from ISDN to high-bandwidth Internet connectivity

summary The Thailand-Hawaii Assessment of Interactive Healthcare Initiative (THAI-HI) is an international distance-education project between two teaching hospitals in Honolulu and Bangkok that uses videoconferencing over three ISDN lines. A ‘morning report’ format is used to discuss clinical cases primarily covering infectious disease and critical-care topics. An audience response system is used at both sites to add interactivity. From July 2001 to May 2002, 816 health-care providers attended 20 clinical conferences. Audiences rated the conferences as highly relevant and as having high training value. Since the ISDN connection is expensive, we plan to convert the telecommunications to a high-bandwidth Internet connection. The Honolulu site will use a 45 Mbit/s commercial connection to the Hawaii Intranetwork Consortium, which links to the Abilene Network on the US mainland. The Bangkok hospital will use a 155 Mbit/s wireless optical connection to UNINET Thailand, which has a 45 Mbit/s circuit to Abilene.

Is UpToDate ready for the ICU?

Owing to the complexity of modern medical care, providers are increasingly turning to a growing arsenal of computer-based references for quick and reliable clinical information. In recent years, UpToDate has emerged as one of the leading subscription-based software packages. The latest version (10.2) was released in June 2002 and includes an impressive 6259 topics from the fields of internal medicine and pediatrics. Thirteen medical subspecialties are also covered, including pulmonary and critical care, gastroenterology, and infectious diseases. In most cases, the authors are established experts in their respective field. Individual topics follow a review article format, including a brief introduction, subject explanation, some future predictions, graphics, tables, and references. The sidebar table of contents allows quick navigation to any section in the article. Whenever possible, links to other related topics are highlighted within the text. Click on a medication name and a pop-up window displays a concise monograph for the drug. Similarly, click on any reference and a pop-up window displays the citation's Medline abstract. Although UpToDate is well regarded by general internists and pediatricians, I decided to challenge the software with a variety of contemporary critical care topics. These included ventilator management in acute respiratory distress syndrome, glycemic control in the intensive care unit (ICU), recombinant activated protein C for sepsis, blood product transfusions in the ICU, corticosteroid administration for refractory shock, and nosocomial infections in the ICU. Overall, UpToDate performed well, and consistently returned the type of results I desired. Rarely did I need to refine my search strategy. Most topics were well written and emphasized the current scientific evidence. Graphics and tables were always printer-friendly. Needless to say, the references were up to date (all topics had been revised in the past six months). Although I recommend it, be prepared to pay. All these features come with a price tag.

Book Review: Topics in Anaesthesia and Critical Care: Anaesthesia and Intensive Care in Neonates and Children

Book Review: Topics in Anaesthesia and Critical Care: Anaesthesia and Intensive Care in Neonates and Children

Critical care education of surgical residents: a survey of general surgery residency programs

Critical care education may vary in general surgery residency programs because no specific guidelines for this type of training exist. In order to determine the current state of resident education in the ICU, a survey was sent to all general surgery program directors. Of the 217 programs responding, 90% had a dedicated ICU rotation. Surgical residents at the PGY-1 (27%) or PGY-2 (46%) level had a 1- (37%) or 2- (49%) month rotation in the ICU. Teaching formats included: bedside rounds (94% of programs), formal lectures (75%), patient problem-based reading (37%), assigned texts (34%), computers (20%), and videotapes (17%) or audiotapes (10%). Procedures were taught mainly by the senior house staff or faculty. Although the curriculum included a broad spectrum of critical care topics, ventilator management and respiratory failure were the only topics universally covered. Resident education in the ICU varies among general surgery programs. The data from this study establish a baseline for following the educational process as more uniform recommendations are developed and the use of novel educational techniques becomes more common.

CRITICAL CARE EDUCATION OF SURGICAL RESIDENTS

Abstract Critical care education may vary in general surgery residency programs because no specific guidelines for this type of training exist. In order to determine the current state of resident education in the ICU, a survey was sent to all general surgery program directors. Of the 217 programs responding, 90% had a dedicated ICU rotation. Surgical residents at the PGY-1 (27%) or PGY-2 (46%) level had a 1- (37%) or 2- (49%) month rotation in the ICU. Teaching formats included: bedside rounds (94% of programs), formal lectures (75%), patient problem-based reading (37%), assigned texts (34%), computers (20%), and videotapes (17%) or audiotapes (10%). Procedures were taught mainly by the senior house staff or faculty. Although the curriculum included a broad spectrum of critical care topics, ventilator management and respiratory failure were the only topics universally covered. Resident education in the ICU varies among general surgery programs. The data from this study establish a baseline for following the educational process as more uniform recommendations are developed and the use of novel educational techniques becomes more common.

Should critical care medicine be a formal part of the undergraduate curriculum?

Medical students were surveyed shortly after completing the third year of medical school. TIle survey was designed to identify those areas of critical care medicine students had been exposed to and expressed interest in learning more about. In addition, the surveys sought to discern the level of confidence students felt with respect to different critical illnesses and intensive care unit (lCU) therapeutic modalities.Finally, the students were asked their opinion regarding the possibility or need for critical care medicine as pan of their medical school curriculum.The three most common topics of interest among medical students who had recently ftnished their third year in medical school were shock, hemodynamic monitoring, and mechanical ventilation. Less than 30% of the students surveyed felt "better-than-average" confidence on anyone of a number of critical care topics and treatment modalities. Of the 80% of students (n = 70) who completed the survey, 91% (n = 64) felt that critical care medicine should be made a pan of the medical school curriculum,6% (n = 4) felt it should not, and 3% (n = 2) were undecided.TIle survey results and the finding that most of the relevant literature acknowledges the need for critical care medicine in medical school has led us to conclude that a national core clerkship or a didactic lecture series in critical care medicine should be carefully designed and implemented into the undergraduate curriculum.

Forum on critical care issues in liver transplantation: Neurological concerns

This edition of “The Crucible” contains the first installment of what we hope will become an ongoing discussion of critical care issues in liver transplantation. After considering an agenda of salient critical care topics, we chose to inaugurate the Critical Care Forum with this discussion on neurological concerns. Intensivists, transplant surgeons, and others involved in the immediate postoperative care of liver transplant recipients generally do not expect a serious neurological setback after transplantation. We expect that a functioning allograft will generally improve neurological impairment, especially in those patients with certain preexisting metabolic encephalopathies. Despite this rather naive optimism, neurological events do occur and account for a large portion of perioperative complications. Clinical series have documented neurological complications in 8.3% to 47% of all patients receiving liver transplantation.1–4 These neurological events, which can range from seizures to stroke to coma, are often first recognized while the patient is still in the intensive care unit. For those of us whose primary specialty is not neurology, the neurological specialist has become an important colleague and an invaluable resource in caring for these patients. We have asked Jeffrey Frank, MD, from The Cleveland Clinic Foundation, Cleveland, OH, to address how he would evaluate and care for the patient with altered consciousness before liver transplantation. Dr Frank is Director of the Neuromedical/Neurosurgical Intensive Care Unit at The Cleveland Clinic Foundation. Dr Frank is a popular speaker on the neurological manifestations of the patient with liver disease and the clinical approach to the patient in coma. Eelco Wijdicks, MD, provides us with his approach to the patient who experiences impaired consciousness after liver transplantation. Dr Wijdicks is a consultant in the Department of Neurology and Co-Director of the Neurology/Neurosurgical Intensive Care Unit at the Mayo Clinic in Rochester, MN. Dr Wijdicks has lectured and written extensively on brain edema, intracranial hemorrhage, central pontine myelinolysis, and the neuromuscular complications that are sometimes observed after liver transplantation. In some clinical series, seizure is the most frequent neurological complication after liver transplantation.1–4 We have asked Zbigniew Wszolek, MD, to address this frequent and sometimes troublesome issue. Dr Wszolek is Medical Director of the Clinical Neurophysiology Laboratory at the University of Nebraska in Omaha. Dr Wszolek has combined his expertise in neurophysiology with an extensive clinical experience in caring for liver transplant recipients. He is uniquely qualified to address the topic of ‘Seizures After Liver Transplantation’.

Manual of Intensive Care Medicine

This manual is a collection of critical care topics. The text is geared toward a bedside approach to diagnosis and treatment and should be a valuable tool for practicing clinicians, especially house officers who may provide direct care to critically ill patients. The chapters are organized so that need to know items can be quickly indexed. The text begins with descriptions of commonly performed special procedures, including endotracheal intubation and central venous, arterial, and pulmonary artery catheterizations. Indications for each procedure are delineated, as are contraindications and complications. Some practical but often overlooked comments are also included. For example, an 8-mm or larger endotracheal tube should be used if bronchoscopy is considered, and the tendency for pulmonary catheters to migrate peripherally as the catheter softens because of body temperature is discussed. Diagrams are kept to a minimum and are simple, eg, anatomy of the great vessels and the neck and

Society of Critical Care Medicine Critical Care Self-Assessment Program III.

Critical Care Medicine encompasses an extremely broad scope. Examination questions were, therefore, chosen to cover a wide variety of critical care topics. A near Gaussian distribution of scores was found for all physician groups studied. We believe the low mean score of 15% reflects the general difficulty of the examination as well as the tendency of many critical care practitioners to master knowledge poorly outside his or her primary specialty. Hopefully, this examination with rationales and references will expose the practitioner to topics and literature with which he or she has not been previously familiar. Only by integrating knowledge from each of the primary specialities can the practitioner provide optimal care for the critically ill. It is our hope that this examination represents a positive learning experience for its past and future participants. If we have stimulated thought, discussion, and further study in the area of critical care medicine, then our efforts in the preparation of this program have been worthwhile.

Establishment of Paediatric and Neonatal Intensive Care Units at Patan Hospital, Kathmandu: Critical Determinants and Future Challenges

Introduction: Although preventive medicine and primary care are priorities in developing countries, they must be supported by appropriate care of sick and extremely sick children in the medical facilities. Lack of resources and absence of skilled physicians and nurses may lead to poor outcomes in critically ill patients. Intensive care of newborns and children is thought to be very expensive with a low cost-benefit ratio. This presentation discusses the critical factors that facilitated the establishment of PICU and NICU in an urban public hospital in Nepal, where a good standard of Level 2 care was already provided. Aims and objectives: A cooperative model of creation and transfer of technology from the West to a resource-poor country was envisaged. PICU and NICU with six beds each were established. Design and setting: The Nick Simons Foundation, USA provided financial support for design, building and furnishing of a new Mother and Child Wing at Patan Hospital. A generous grant of $300,000 again by the Nick Simons Foundation helped equip the units. Donated equipments also included procedures, medication and storage carts. Methodology: A total of 22 volunteers, 21 from USA and one from Netherlands, were recruited to complete the three months of training. An extensive curriculum was prepared. The trainer team had monthly teleconferences and regular communications with the Chief of Paediatric Services and Nursing Director of Patan Hospital via e-mails and telephone. Responsibilities of volunteers and the host hospital were identified. Results: After 3 years of preparation, the project started in June 2009. All day lectures on topics in critical care, mock case scenarios, practical equipment training and simulated procedures led to the graduation of 60 nurses. Twenty five physicians were trained for three months. The expert team worked with the locals in preparing the units, arranging furniture and equipment, stocking carts, making inventory and preparing protocols. A protocol handbook was developed on topics such as mechanical ventilation, sedation, admission/discharge criteria, procedures and management of different disease states. Various charts such as nurse observation charts, notes by residents, procedure hand offs at change of shifts were designed and printed. Infection control practices and methods of sterilizing non disposable articles were identified and protocols written. At the end of three months the units were functioning with trained local manpower and reasonable modern equipment. Conclusion: Developing nations may not have enough resources to establish much needed critical care facilities. Developed countries can help by funding basic infrastructure and providing expertise in order to transfer knowledge and technology. Involvement in planning from the beginning and training at the host site is a preferred model of transfer of technology. Key words: Paediatric Intensive Care Unit (PICU); Neonatal Intensive Care Unit (NICU); Patan Hospital DOI: 10.3126/jnps.v31i1.4161J Nep Paedtr Soc 2010;31(1):49-56