Charles G. Durbin

Guidelines for critical care medicine training and continuing medical education.

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.

TEAM MODEL: ADVOCATING FOR THE OPTIMAL METHOD OF CARE DELIVERY IN THE INTENSIVE CARE UNIT

Objective:To review published data on the team model of intensive care unit (ICU) care delivery. Design:Nonexhaustive, selective literature search. Setting:Review of literature published in the English language. Patients/Subjects:Humans cared for in ICUs. Interventions:None. Results:The team model for delivery of ICU care reduces mortality, ICU length of stay, hospital length of stay, and cost of care. Convincing data suggest that merely having daily rounds led by an intensivist enhances patient care significantly. Further improvements can be obtained by maintaining a nurse-to-patient ratio of no greater than 1:2, adding critical care pharmacists, and providing dedicated respiratory therapists to the ICU team. Conclusion:Current and looming shortages of all ICU healthcare providers is a barrier to universal implementation of the team model. Advocating for the ICU team model for critical care delivery requires local, regional, national, and international activities for success.

The anesthesiologist in critical care medicine: past, present, and future.

AT the beginning of the new millennium, anesthesiabased critical care medicine (CCM) is at a crossroads. Although anesthesiologists took a leadership role in the initial development of critical care, today the American critical care anesthesiologist is an endangered species, overshadowed in numbers and political clout by colleagues from pulmonary medicine and surgery. In contrast to Europe, where anesthesiologists play a dominant role in critical care, in the United States, anesthesia-based CCM is a peripheral subspecialty of anesthesiology practiced by a small minority. As we seek to broadly redefine the role of the anesthesiologist both inside and outside the operating room, it is timely to ask the question, “Is there a future for anesthesiologists in critical care?” Can we regain a leadership role and thereby enhance our specialty as a whole, or are critical care anesthesiologists doomed to increasing irrelevance as our numbers dwindle toward extinction? This special article is an editorial essay and reflects the observations and thoughts of the leadership of the American Society of Critical Care Anesthesiologists, a component society of the American Society of Anesthesiologists, as well as the perspective of a distinguished European colleague (L. G.).

More reliable oximetry reduces the frequency of arterial blood gas analyses and hastens oxygen weaning after cardiac surgery: A prospective, randomized trial of the clinical impact of a new technology

ObjectiveEvaluation of the impact on clinical care of improved, innovative oximetry technology. DesignRandomized, prospective trial. SettingPostcardiac surgery intensive care unit in a major teaching hospital. PatientsA total of 86 patients after undergoing coronary artery bypass surgery. InterventionsAll patients were monitored with two oximeters, one employing conventional oximetry (conventional pulse oximeter, CPO) and one using an improved innovative technology (innovative pulse oximeter, IPO), on different fingers of the same hand. The outputs from both devices were collected continuously by computer, but only one device was randomly selected and displayed for clinicians. Measurements and Main ResultsThe amount and percentage of nonfunctional monitoring time was collected and found to be much greater for the CPO than the IPO (8.7% ± 16.4% for CPO vs. 1.2% ± 3.3% for IPO, p = .000256). Time to extubation was not different between the two groups (634 ± 328 mins for IPO vs. 706 ± 459 mins for CPO). Clinicians managing patients with the more reliable IPO weaned patients faster to an Fio2 of 0.40 (176 ± 111 mins for IPO vs. 348 ± 425 mins for CPO, p = .0125), obtained fewer arterial blood gas measurements (2.7 ± 1.2 for IPO vs. 4.1 ± 1.6 for CPO, p = .000015), and made the same number of ventilator changes during this weaning process (2.9 ± 1.2 for IPO vs. 2.9 ± 1.7 for CPO). ConclusionsProvision of more reliable oximetry allows caregivers to act in a more efficient and cost-effective manner in regard to oxygen weaning and use of arterial blood gas measurements. Investigating the effect of a monitor on the process of care, rather than simply its accuracy and precision, is a useful, relevant paradigm for evaluating the value and impact of a new technology.

Cardiovascular Effects of Nalbuphine in Patients with Coronary or Valvular Heart Disease

Although the hemodynamic changes produced by small doses of nalbuphine given to patients with cardiac disease are minimal, the cardiovascular effects of large doses which have been used as supplements for general anesthesia have not been investigated. Cardiovascular variables were measured after incremental doses of nalbuphine, up to 2 or 3 mg/kg in fourteen patients with coronary artery disease with normal left ventricular function and in seven patients with mitral valve disease. No significant changes in cardiac index, stroke work index, mean arterial pressure, pulmonary diastolic or wedge pressure, heart rate, or central venous pressure occurred in the preoperative period. However, nalbuphine alone did not produce surgical anesthesia and the addition of diazepam, nitrous oxide, or halothane was required in all patients. The addition of halothane coupled with surgical stimulation significantly decreased cardiac and stroke indices, increased mean arterial and pulmonary wedge pressures, and increased systemic vascular resistance in patients with coronary artery disease. In patients with mitral valve disease, following surgical incision, there were small but significant decreases in cardiac index and left ventricular stroke work index, and increases in systemic vascular resistance. Despite its lack of deleterious hemodynamic effects, the place of nalbuphine in the armamentarium of the anesthesiologist must be limited to use as a premedicant, as an adjunct to balanced anesthesia, or for postoperative pain relief.

Transitioning the Respiratory Therapy Workforce for 2015 and Beyond

The American Association for Respiratory Care established a task force in late 2007 to identify likely new roles and responsibilities of respiratory therapists (RTs) in the year 2015 and beyond. A series of 3 conferences was held between 2008 and 2010. The first task force conference affirmed that the healthcare system is in the process of dramatic change, driven by the need to improve health while decreasing costs and improving quality. This will be facilitated by application of evidence-based care, prevention and management of disease, and closely integrated interdisciplinary care teams. The second task force conference identified specific competencies needed to assure safe and effective execution of RT roles and responsibilities in the future. The third task force conference was charged with creating plans to change the professional education process so that RTs are able to achieve the needed skills, attitudes, and competencies identified in the previous conferences. Transition plans were developed by participants after review and discussion of the outcomes of the first two conferences and 1,011 survey responses from RT department managers and RT education program directors. This is a report of the recommendations of the third task force conference held July 12-14, 2010, on Marco Island, Florida. The participants, who represented groups concerned with RT education, licensure, and practice, proposed, discussed, and accepted that to be successful in the future a baccalaureate degree must be the minimum entry level for respiratory care practice. Also accepted was the recommendation that the Certified Respiratory Therapist examination be retired, and instead, passing of the Registered Respiratory Therapist examination will be required for beginning clinical practice. A date of 2020 for achieving these changes was proposed, debated, and accepted. Recommendations were approved requesting resources be provided to help RT education programs, existing RT workforce, and state societies work through the issues raised by these changes.

Neuromuscular blocking agents and sedative drugs : clinical uses and toxic effects in the critical care unit

The use of sedatives and muscle relaxants is common in the ICU. Therapeutic goals should be carefully established. Monitoring of desired effects and toxic side effects is essential to avoid preventable morbidity.

Is industry guiding the sepsis guidelines? A perspective.

I mprovements in clinical care require change in both clinicians’ behavior and the systems in which they practice. Information published in peer-reviewed journals and continuing medical education have been the primary methods available to inform physicians and other caregivers of advances in medical practice. The impact of these educational activities is limited, however. In 1999, the Institute of Medicine published a landmark report, “To Err Is Human: Building a Safer Health System” (1). The report identified, in part, a widening gap between what research has demonstrated will improve patient outcomes and clinicians’ actual practice. To improve care and reduce unnecessary variation in clinical practice, professional societies have developed and disseminated evidence-based practice guidelines (2).

Pulmonary artery catheter deterioration during hydrochloric acid infusion for the treatment of metabolic alkalosis.

Hydrochloric acid (HCl) infusions for the correction of metabolic alkalosis have been used for 20 yr. In the critical care setting, HCl is usually infused through a central venous or pulmonary artery (PA) catheter. In two patients receiving HCl infusions through a PA catheter, we observed and examined solid yellow particulate material in the aspirating syringe while testing the proximal lumen for patiency. We carried out in vitro investigation infusing PA catheters with 0.1, 0.2, 0.3, and 0.4 normal HCl at 20 degrees, 38 degrees, and 42 degrees C for 24 and 48 h. Although frank catheter deterioration could not be documented, the surface and interior of those catheters infused with greater than 0.1 normal HCl changed texture, indicating a change in catheter composition. Exceeding a concentration of 0.1 normal is not recommended when HCl is infused through PA catheters.

Survey of Respiratory Therapy Education Program Directors in the United States

OBJECTIVE: As background for the American Association for Respiratory Care (AARC) third 2015 and Beyond conference, we sought information and opinions on the ability of the current respiratory therapy education infrastructure to make changes that would assure competent respiratory therapists in the envisioned healthcare future. METHODS: After pilot testing and refining the questions, we invited the directors of 435 respiratory therapy programs (based in 411 colleges) that were fully accredited or in the process of being accredited by the Commission on Accreditation for Respiratory Care as of May, 2010, to participate in the survey. RESULTS: Three-hundred forty-eight program directors (80%) provided valid survey responses. Three of the 5 competencies related to evidence-based medicine and respiratory care protocols were taught less often in the associate-degree programs than in the baccalaureate-degree programs. Eighty percent of the baccalaureate-degree programs, compared to 42% of the associate-degree programs, instruct students how to critique published research (P < .001). Only 34% of the associate-degree programs teach students the general meaning of statistical tests, compared to 78% of the baccalaureate-degree programs (P < .001). Ninety-four percent of the baccalaureate-degree programs, versus 81% of the associate-degree programs, teach the students to apply evidence-based medicine to clinical practice (P = .01). Teaching students how to describe healthcare and financial reimbursement systems and the need to reduce the cost of delivering respiratory care (a leadership competency identified by the second 2015 and Beyond conference) was significantly more common in the baccalaureate-degree programs (72%) than in the associate-degree programs (56%) (P = .03). Other competencies showed trends toward differences, and the baccalaureate-degree programs reported higher percentages of success than the associate-degree programs. CONCLUSIONS: There are important differences between the baccalaureate-degree and associate-degree programs.