Ake Grenvik

Outcome of intensive care of the "oldest-old" critically ill patients.

Objective:To determine the short-term and long-term outcome of critically ill “oldest-old” (≥85 yrs) patients. Design:Retrospective chart review and follow-up telephone interview. Setting:ICUs at a tertiary care hospital. Methods:The medical records of all patients ≥85 yrs of age admitted to the ICUs during 1988 were reviewed. Demographic information, severity of illness, major interventions, mortality rate, and hospital charges were examined. A follow-up telephone interview was conducted to determine the quality of life and mortality rate after discharge. Results:Of 34 patients ≥85 yrs of age admitted to the ICU, 21 (62%) survived to discharge from the hospital, and 13 (62%) of these 21 patients were discharged to home. Mean ± so hospital charges were

Cardiorespiratory Effects of Flexible Fiberoptic Bronchoscopy in Critically III Patients

34,738 ± 34,366. Seventeen of the 21 patients were contacted for long-term follow-up, and ten of these patients were alive at a mean follow-up time of 18 ± 10 months (range 1 to 32). Eight of the ten patients described their quality of life as fair or good. Conclusion:These findings suggest that age alone may be an inappropriate criterion for allocation of ICU resources.

Guidelines for critical care medicine training and continuing medical education.

The flexible fiberoptic bronchoscope is used increasingly often as a multipurpose instrument in critical care medicine. In poor risk patients who need continuous mechanical ventilation, rigid open tube bronchoscopy is a problem. With the flexible fiberoptic bronchoscope, however, diagnostic and therapeutic procedures can be carried out without interruption of ongoing mechanical ventilation. This procedure offers the possibility of bronchoscopy with reduced risk in debilitated patients. However, in these critically ill patients, the cardiopulmonary system is functioning at the borderline of its ability. Therefore, even the small changes in ventilation pattern caused by flexible fiberoptic bronchoscopy (FFB) may in some cases cause dangerous cardiopulmonary distress. For example, changes of intrabronchial pressure, tidal volume, PaO2, PaCO2 and cardiac output may be caused by the procedure. Further, it is of great importance to restrict suction through the instrument to short periods to avoid dangerous alterations in the ventilation perfusion relationship. Since serious complications may occur, it is mandatory that the bronchoscopist be aware of the potential pathophysiologic effects of FFB during mechanical ventilation of critically ill patients.

Nosocomial lung infection and its diagnosis

ObjectiveCritical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care. ParticipantsA multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine. ScopePhysician education in critical care medicine in the United States should encompass all disciplines that provide care in the intensive care unit and all levels of training: from medical students through all levels of postgraduate training and continuing medical education for all providers of clinical critical care. The scope of this guideline includes physician education in the United States from residency through ongoing practice after subspecialization. Data Sources and SynthesisRelevant literature was accessed via a systematic Medline search as well as by requesting references from all panel members. Subsequently, the bibliographies of obtained literature were reviewed for additional references. In addition, a search of organization-based published material was conducted via the Internet. This included but was not limited to material published by the American College of Critical Care Medicine, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and other primary and specialty organizations. Collaboratively and iteratively, the task force met, by conference call and in person, to construct the tenets and ultimately the substance of this guideline. ConclusionsGuidelines for the continuum of education in critical care medicine from residency through specialty training and ongoing throughout practice will facilitate standardization of physician education in critical care medicine.

From Resusci-Anne to Sim-Man: the evolution of simulators in medicine.

Nosocomial pneumonia occurs in 0.5% to 5.0% of all hospital admissions and is responsible for 15% of hospital deaths. Up to 60% of ICU patients may develop pneumonia, depending on the severity of their underlying disease. Despite the availability of potent antibiotics, ICU patients who develop Gram-negative pneumonia have a disturbingly high mortality rate. Specific etiologic diagnosis is frequently lacking because microbiological samples are commonly contaminated by oropharyngeal secretions which are colonized by Gram-negative bacilli (GNB) in up to 100% of ICU patients. Great controversy surrounds the value of various methods used to diagnose nosocomial pneumonia. Clinical criteria of pneumonia include fever, leukocytosis, purulent tracheobronchial secretions, and a new infiltrate on chest x-ray—all of which are also frequently observed in patients free of pneumonia. Tracheobronchial secretions are often contaminated by microorganisms colonizing the upper airways and their examination may provide misleading information and result in patient mismanagement. Blood cultures are valuable but positive in only a small proportion of patients with nosocomial pneumonia. Transtracheal and transthoracic aspiration are unsatisfactory in the intubated patient requiring mechanical ventilation. Immunologic techniques like countercurrent immunoelectrophoresis are promising but presently inadequate to screen for a wide variety of organisms. Transbronchial or open-lung biopsy may be considered if the pneumonia is thought to be due to opportunistic organisms rather than bacteria. From a practical standpoint, the least misleading information is probably obtained by quantitative cultures obtained from the lower airways by fiberoptic bronchoscopy, employing the plugged telescoping-catheter brush technique.

Flexible fiberoptic bronchoscopy in critical care medicine: Diagnosis, therapy and complications

Simulators were introduced in education as a tool to make advanced training standardized, less expensive, and without danger to those involved. In 1922 in the United States, Edward Link presented his homemade flight simulator, which became common place in both military and civilian aviation, known as the “Link Trainer.” However, several decades passed before this form of training became accepted in medicine. Already in the early 1960s, Peter Safar had become involved in medical simulation through opportunistic exposure and innovative research. Interested in potential reversal of death from accidents and medical problems causing cardiac arrest, he was disturbed by the poor results of the current resuscitation technique of nonbreathing victims. In discussions with Dr. James Elam, Peter Safar learned that artificial ventilation could be efficiently provided with normal arterial blood gases in anesthetized individuals simply by blowing into the endotracheal tube (1). In the late 1950s, as chief anesthesiologist at Baltimore City Hospital, Dr. Safar undertook his daring experiments on sedated and curarized volunteers. He demonstrated unequivocally the lack of effect of arm lift/chest pressure ventilation efforts, whereas exhaled air provided through mouth-to-mouth ventilation was not only superior but also resulted in both adequate oxygenation and CO2 elimination. This study was published in JAMA in 1958 (2), and Peter Safar reported on his results at an anesthesiology/cardiopulmonary resuscitation congress in Norway. In 1961, Bjorn Lind and other prominent Norwegian anesthesiologists, who participated in this congress, brought the idea of providing appropriate cardiopulmonary resuscitation training equipment to the attention of Asmund Laerdal, a successful entrepreneur in Stavanger, Norway, whose main business was the manufacturing of toys made of soft plastic materials. Laerdal promptly designed a full-size training mannequin for mouth-to-mouth ventilation. The airway could be obstructed, and it was necessary to use hyperextension of the neck and forward thrust of the chin to open the airway before initiating insufflation of air into the mannequin by mouth-tomouth technique as described by Peter Safar. At the recommendation of Dr. Lind, Asmund Laerdal visited Peter Safar in Baltimore for a demonstration of his mannequin. At that time, Kowenhoven, Knickerbocker, and Jude had just published their observation, showing that external chest compression could produce blood flow in cardiac arrest victims. Peter Safar advised Asmund Laerdal to include an internal spring attachment to the chest wall that would permit simulation of cardiac compression; thus, the possibility of training the ABC of cardiopulmonary resuscitation on the simulator was born, with A standing for airway, B for breathing, and C for circulation. This early simulator of a dying victim not breathing and without a heart beat became known as Resusci-Anne, and its utilization rapidly spread around the world. In 1968, Ake Grenvik of Sweden joined Peter Safar’s critical care medicine training program in Pittsburgh. He realized the many problems in training physicians to use proper technique when managing critically ill and injured patients, in whom relatively minor complications could create life-threatening problems leading to death. Through the close collaboration between Peter Safar’s department of anesthesiology and critical care medicine on the American side and the Laerdal Corporation in Norway on the European side, Ake Grenvik, too, became very much involved in the exchange of ideas between Pittsburgh and Stavanger. After Asmund Laerdal’s premature death of cancer in 1981, his son Tore Laerdal became the leader in their Norwegian family business. He continued the traditionally close relations and support of the Safar group. Having used a Link trainer as a former flight surgeon in the Swedish Air Force, Ake realized the need for advanced simulation training in critical care medicine and made repeated recommendations for the Laerdal Corporation to expand into modern computerized simulation technology. The Laerdal Corporation wisely awaited the right opportunity to start this expansion. In 1995, only two, and very expensive, human simulators were available in the United States. At that time, Dr. Peter Winter served as chairman of the department of anesthesiology and critical care medicine after Peter Safar, who had withdrawn into his International Resuscitation Research Center for full-time investigations in the field of reanimatology. Peter Winter had the foresight to acquire one of the available simulators, although at the very high cost of approximately

Hemodynamic response to discontinuance of mechanical ventilation.

250,000. Drs. Rene Gonzales and John Schaefer of his Department were appointed director and associate director, respectively, of this simulation center at the University of Pittsburgh. These two ingenious young anesthesiologists designed a far less expensive, much more practical, realistic, and mobile simulation module, which was patented. The Medical Plastics Limited Corporation in Texas assumed responsibility for manufacturing of this new simulator. This company was From the Safar Center for Resuscitation Research (PMK) and the Department of Critical Care Medicine (AG, PMK), University of Pittsburgh School of Medicine, Pittsburgh, PA.

Blood flow and perfusion pressure during open-chest versus closed-chest cardiopulmonary resuscitation in pigs

Flexible fiberoptic bronchoscopy was evaluated in 71 procedures in 55 patients. Two-thirds of these procedures were carried out in patients with ongoing mechanical ventilation as their respiratory failure contraindicated rigid bronchoscopy. A wide variety of important diagnostic information was obtained. FFB caused no mortality or serious complications. Transient tachycardia occurred in several patients, cardiac arrhythmia in two and mediastinal emphysema in one patient. Retained secretions and atelectasis were the indications for 53 FFBs; 43 (81%) of these procedures were successful in improving aeration as evaluated with radiography.

Differential lung ventilation with PEEP in the treatment of unilateral pneumonia.

Homodynamic monitoring during discontinuance of mechanical ventilation revealed that some post-cardiomy patients who were ready for weaning, by the usual criteria, responded with a sudden unexpected reduction in cardiac output. This paradoxical decrease in cardiac output was not correlated with a decreased arterial oxygen tension or other blood gas changes, but was associated with reduced oxygen availability and consumption as well as increased pulmonary vascular resistance. Subsequent weaning attempts were successful in 16 of these 18 patients and repeated cardiac output determinations in a few showed “recovery” of the heart with in-creased cardiac output upon discontinuance of the ventilator.

Resuscitation from severe brain trauma

OBJECTIVE To evaluate the blood flow and perfusion pressure differences observed during open- vs. closed-chest cardiopulmonary resuscitation (CPR), including the effects of epinephrine and sodium bicarbonate administration. DESIGN Prospective, randomized, controlled trial. SETTING Experimental animal laboratory in a university hospital. SUBJECTS A total of 35 anesthetized piglets. INTERVENTIONS After tracheostomy and insertion of arterial, right atrial, and pulmonary arterial catheters, thoracotomy was performed with placement of a pulmonary arterial flow probe and left atrial catheter. Ventricular fibrillation was induced and followed by 15 mins of either open-chest (n = 14) or closed-chest (n = 21) CPR. A 4-min infusion of 50 mmol of sodium bicarbonate or saline was added at the start of CPR. After 8 mins of CPR, 0.5 mg of epinephrine was given intravenously, and after 15 mins, direct current (DC) shocks were used to revert the heart to sinus rhythm. MEASUREMENTS AND MAIN RESULTS Blood flow was studied using transit-time ultrasound flowmetry. In an extended group, intrathoracic pressure was measured for calculation of transmural pressure. Before epinephrine administration, mean pulmonary arterial flow (cardiac output) was reduced: a) during closed-chest CPR relatively more than pulmonary perfusion pressure but in proportion to systemic perfusion pressure; b) during open-chest CPR relatively less than pulmonary perfusion pressure but still in proportion to systemic perfusion pressure. Epinephrine administration temporarily increased systemic perfusion pressure during both closed- and open-chest CPR but temporarily decreased pulmonary perfusion pressure only during closed-chest CPR. After epinephrine administration, cardiac output temporarily decreased during both closed-and open-chest CPR. CONCLUSIONS Open-chest CPR resulted in better cardiac output and systemic perfusion pressure than closed-chest CPR. However, cardiac output values obtained with both methods were much lower than previously reported. After epinephrine administration, cardiac output became extremely low with both methods.