Baruch S. Fertel

Extracorporeal Removal Techniques for the Poisoned Patient: A Review for the Intensivist

The kidney is able to rapidly eliminate many water-soluble xenobiotics (exogenous chemicals). However, in the face of extraordinary serum concentrations of these xenobiotics or renal dysfunction, alternative elimination techniques often become necessary. Extracorporeal removal (ECR) techniques are used to increase the clearance of xenobiotics. These techniques include hemodialysis (HD), charcoal hemoperfusion (HP), and modalities grouped under the heading of continuous renal replacement therapy (CRRT): continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodiafiltration (CVVHDF). Extracorporeal removal is limited to patients with significant or potentially significant clinical poisoning because the resources required to perform ECR are great. Therefore, most patients who are treated with these techniques are being cared for in intensive care units (ICUs). Our goal in this review is to discuss the properties that make xenobiotics amenable to removal by ECR and the advantages and disadvantages of the individual techniques. We discuss xenobiotics that constitute clear indications for ECR, including the toxic alcohols, salicylates, and lithium. We review the use of CRRT, a modality for which clear indications for treatment of poisonings are currently lacking.

Disaster preparedness: hospital decontamination and the pediatric patient--guidelines for hospitals and emergency planners.

In recent years, attention has been given to disaster preparedness for first responders and first receivers (hospitals). One such focus involves the decontamination of individuals who have fallen victim to a chemical agent from an attack or an accident involving hazardous materials. Children often are overlooked in disaster planning. Children are vulnerable and have specific medical and psychological requirements. There is a need to develop specific protocols to address pediatric patients who require decontamination at the entrance of hospital emergency departments. Currently, there are no published resources that meet this need. An expert panel convened by the New York City Department of Health and Mental Hygiene developed policies and procedures for the decontamination of pediatric patients. The panel was comprised of experts from a variety of medical and psychosocial areas. Using an iterative process, the panel created guidelines that were approved by the stakeholders and are presented in this paper. These guidelines must be utilized, studied, and modified to increase the likelihood that they will work during an emergency situation.

The degree of bandemia in septic ED patients does not predict inpatient mortality

BACKGROUND A delay in diagnosis of sepsis and appropriate treatment increases subsequent mortality. An association with the degree of bandemia, or the presence of immature neutrophils in the white blood cell count, has not been explored in septic patients presenting to the emergency department (ED). We hypothesized that the presenting band levels would be higher in septic patients who die in hospital compared with survivors. METHODS This study reviewed charts of ED patients presenting with sepsis to a single urban, academic, tertiary care ED with an annual census of 80,000 visits. Patients were included if they had bandemia assessed and were eligible for early goal-directed therapy. Reviewers blinded to the study purpose abstracted data using predetermined definitions. The band level was compared between patients who died and those who survived to discharge using the Mann-Whitney U test. Logistic regression was used to estimate the effect of bandemia levels on the odds of death. RESULTS Ninety-six patients meeting inclusion criteria were enrolled; 2 were excluded with incomplete data. Mean age was 59 years, 53% were white, and 51% were male. Thirty-two patients (34%) died during admission. The median band levels in patients who died was 17% (range, 0%-67%); and in patients surviving to discharge, the median band level was 9% (range, 0%-77%) (difference in medians, 8%; CI(95), -27.04 to 11.04; P = .222). CONCLUSIONS The band level on presentation was not found to be associated with inpatient mortality in ED patients with sepsis who are eligible for early goal-directed therapy.

Patients who use multiple EDs: quantifying the degree of overlap between ED populations.

Introduction The degree to which individual patients use multiple emergency departments (EDs) is not well-characterized. We determined the degree of overlap in ED population between three geographically proximate hospitals. Methods This retrospective cohort study reviewed administrative hospital records from 2003 to 2007 for patients registered to receive ED services at an urban academic, urban community, and suburban community ED located within 10 miles of one another. We determined the proportion who sought care at multiple EDs and secondarily characterized patterns of repeat encounters. Results There were 795,176 encounters involving 282,903 patients. There were 89,776 (31%) patients with multiple encounters to a single ED and 39,920 (14%) patients who sought care from multiple EDs. The 39,920 patients who sought care from multiple EDs generated 185,629 (23%) of all encounters. Patients with repeat encounters involving multiple EDs were more likely to be frequent or highly frequent users (30%) than patients with multiple encounters to a single ED (14%). Conclusion While only 14% of patients received care from more than one ED, they were responsible for a quarter of ED encounters. Patients who use multiple EDs are more often frequent or highly frequent users than are repeat ED visitors to the same ED. Overlap between ED populations is sufficient to warrant consideration by multiple domains of research, practice, and policy.

Evaluation of hospital mass screening and infection control practices in a pandemic influenza full-scale exercise.

OBJECTIVE Nonpharmacologic interventions such as limiting nosocomial spread have been suggested for mitigation of respiratory epidemics at health care facilities. This observational study tested the efficacy of a mass screening, isolation, and triage protocol in correctly identifying and placing in a cohort exercise subjects according to case status in the emergency departments at 3 acute care hospitals in Brooklyn, New York, during a simulated pandemic influenza outbreak. METHODS During a 1-day, full-scale exercise using 354 volunteer victims, variables assessing adherence to the mass screening protocol and infection control recommendations were evaluated using standardized forms. RESULTS While all hospitals were able to apply the suggested mass screening protocol for separation based on case status, significant differences were observed in several infection control variables among participating hospitals and different hospital areas. CONCLUSIONS Implementation of mass screening and other infection control interventions during a hospital full-scale exercise was feasible and resulted in measurable outcomes. Hospital drills may be an effective way of detecting and addressing variability in following infection control recommendations.