Cristin Mount

Use of a protocolized approach to the management of sepsis can improve time to first dose of antibiotics

PURPOSE The Surviving Sepsis Guidelines established recommendations for early recognition and rapid treatment of patients with sepsis. Recognizing systemic difficulties that delayed the application of early goal-directed therapy, the Emergency Department and Critical Care leadership instituted a sepsis protocol to identify patients with sepsis and expedite antibiotic delivery. We aimed to determine if the sepsis protocol improved the time to first dose of antibiotics in patients diagnosed with sepsis. MATERIALS AND METHODS We performed a retrospective chart review of patients with sepsis comparing the time from antibiotic order placement to the first dose of antibiotic therapy over a 3-year period. Patients who received vancomycin and ciprofloxacin underwent additional subgroup analysis, as these antibiotics were made available by protocol for use without infectious disease consultation. RESULTS The average time to first dose of antibiotics for the presepsis protocol group was 160 minutes, and the average time for the sepsis protocol group was 99 minutes. Fifty-eight patients received vancomycin, and 30 received ciprofloxacin, with a decrease in time of 65 minutes and 41 minutes, respectively. CONCLUSIONS Initiation of a sepsis protocol, which emphasizes early goal-directed therapy, can improve time to administration of first dose of antibiotics.

Analysis of an electromagnetic tube placement device versus a self-advancing nasal jejunal device for postpyloric feeding tube placement

BACKGROUND Initiation of enteral feeding is an important part of the best practice model for critically ill patients. Although nasogastric feeding is appropriate for the majority of patients requiring short-term nutrition support, certain patients benefit greatly from postpyloric feeding. OBJECTIVE To determine which of 2 specialized enteral tube systems achieved postpyloric placement on initial insertion attempt most efficiently. DESIGN Retrospective study comparing the Tiger 2 tube (T2T) and Cortrak Enteral Access System (C-EAS). SETTING Academic medical center, mixed intensive care unit (ICU). PATIENTS All patients admitted to the ICU between 2009 and 2013 who had either a C-EAS or T2T placed. MEASUREMENTS Success rate for postpyloric placement, congruency of real-time tube placement with x-ray confirmation for C-EAS, and complication rates. RESULTS Seventy-one T2T and 74 C-EAS patients were included. The T2T was postpyloric 62% (44/71) of attempted placements. C-EAS was postpyloric 43% (32/74) of attempted placements (P = 0.03). C-EAS tracings accurately reflected chest x-ray findings 83% and 82% for postpyloric and non-postpyloric insertion, respectively. During the entire study period, no adverse events were recorded. CONCLUSION Our institution evaluated 2 different systems designed to ensure postpyloric placement of a small bore feeding tube. No literature exists directly comparing the 2 systems. Our retrospective review, although limited, showed that the T2T was more effective at postpyloric placement on first attempt. Although 1 benefit of the C-EAS system may be real-time visualization, our practice showed this system to be user dependent, which likely led to less success with postpyloric placement.

Critical care medicine at Walter Reed Army Medical Center in support of the global war on terrorism

Background:The military medical experience during wartime is unique and distinct from civilian medical practice. Historically, the military has produced innovations resulting in both civilian and military medical care advances, and our current conflict is no different. In this article, we provide a description of the medical and surgical intensive care units at Walter Reed, their history, and approach to new issues encountered in the care of Operation Iraqi Freedom and Operation Enduring Freedom soldiers. Additionally, descriptive statistics regarding the number of Operation Iraqi Freedom and Operation Enduring Freedom soldiers admitted to the critical care service, basic demographics, general category of injury, and discussion of intensive care unit issues unique to this patient population, such as Acinetobacter and traumatic brain injury, are presented. Discussion:We intend to provide a general description of our Operation Iraqi Freedom/Operation Enduring Freedom trauma population cared for by the critical care service at Walter Reed Army Medical Center, as well as a discussion of our approach to caring for some of their unique issues, to detail experiences that could translate into improvements for civilian trauma centers.

Developing a Diary Program to Minimize Patient and Family Post-Intensive Care Syndrome.

ABSTRACT A series of evidence‐based interventions beginning with an intensive care unit diary and a patient/family educational pamphlet were implemented to address the long‐term consequences of critical illness after discharge from the intensive care unit, bundled as post‐intensive care syndrome and post‐intensive care syndrome‐family. An extensive literature review and nursing observations of the phenomenon highlighted the potential for this project to have a favorable impact on patients, their families, and the health care team. The goal of this article is to explain the education of all stakeholders; the introduction of the diary, video, and educational pamphlet; and the evaluation of the acceptance of these interventions. This process began with an informal evaluation of the educational products and overall perception of the usefulness of the diary by patients, family members, and staff. The efforts described contribute to the evidence base supporting diaries as an adjunct to intensive care.

An End-of-Year Oral Examination for Internal Medicine Residents: An Assessment Tool for the Clinical Competency Committee.

BACKGROUND Comprehensive evaluations of clinical competency consume a large amount of time and resources. An oral examination is a unique evaluation tool that can augment a global performance assessment by the Clinical Competency Committee (CCC). OBJECTIVE We developed an oral examination to aid our CCC in evaluating resident performance. METHODS We reviewed tools used in our internal medicine residency program and other training programs in our institution. A literature search failed to identify reports of a similar evaluation tool used in internal medicine programs. We developed and administered an internal medicine oral examination (IMOE) to our postgraduate year-1 and postgraduate year-2 internal medicine residents annually over a 3-year period. The results were used to enhance our CCCs discussion of overall resident performance. We estimated the costs in terms of faculty time away from patient care activities. RESULTS Of the 54 residents, 46 (86%) passed the IMOE on their first attempt. Of the 8 (14%) residents who failed, all but 1 successfully passed after a mentored study period and retest. Less than 0.1 annual full-time equivalent per faculty member was committed by most faculty involved, and the time spent on the IMOE replaced regular resident daily conference activities. CONCLUSIONS The results of the IMOE were added to other assessment tools and used by the CCC for a global assessment of resident performance. An oral examination is feasible in terms of cost and can be easily modified to fit the needs of various competency committees.

A rare case of acute diffuse alveolar hemorrhage following initiation of amiodarone: a case report.

Amiodarone is effective for treating ventricular and supraventricular tachyarrhythmias, despite potential side effects which can include injury to the liver, thyroid, cornea, skin, and neuromuscular system. Acute lung toxicity is a known but rare side effect of amiodarone use, most commonly taking the form of an acute or subacute interstitial pneumonitis. Diffuse alveolar hemorrhage is a rare reaction, with few case reports documented in the literature since amiodarone became widely used in the early 1980s. We report the case of a patient who developed severe respiratory failure and diffuse alveolar infiltrates within 72 hours of initiating amiodarone therapy. Postmortem lung histology confirmed the diagnosis of diffuse alveolar hemorrhage. The case presentation and proposed mechanisms of action will be reviewed here.

Acute onset of tetraparesis, arreflexia and respiratory distress in an otherwise healthy male.

The patient is a previously healthy Eastern-African man in his late 20s, with unknown vaccination status who presented to a US Army Combat Hospital in Iraq with acute upper and lower extremity weakness progressing to respiratory distress requiring intubation over the course of 12 h. His only antecedent symptoms were weakness and nausea. Laboratories including complete blood count, C reactive protein, cerebrospinal fluid analysis, venous blood gas, rapid HIV and chemistry were normal. Non-contrast head CT was normal. The patient was extubated after 24 h but continued to exhibit 2/5 strength in bilateral upper and lower extremities with absence of deep-tendon reflexes. At 48 h of illness it was discovered that the prior to his presentation the patient had a significant life stressor which had since been resolved. Upon discovery that this stressor had been resolved, the patients symptoms improved over the subsequent 4–6 h and was discharged after 24 h without further complication.

A Non-Comparative Prospective Pilot Study of Ketamine for Sedation in Adult Septic Shock

Introduction Sedation and analgesia in the intensive care unit (ICU) for patients with sepsis can be challenging. Opioids and benzodiazepines can lower blood pressure and decrease respiratory drive. Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist that provides both amnesia and analgesia without depressing respiratory drive or blood pressure. The purpose of this pilot study was to assess the effect of ketamine on the vasopressor requirement in adult patients with septic shock requiring mechanical ventilation. Materials and Methods We conducted a two-phase study in a multi-disciplinary adult ICU at a tertiary medical center. The first phase was a retrospective chart review of patients admitted with septic shock between July 2010 and July 2011; 29 patients were identified for a historical control group. The second phase was a prospective, non-randomized, open-label pilot study. Patients were eligible for inclusion if they were 18-89 yr of age with a diagnosis of septic shock, who also required mechanical ventilation for at least 24 h, concomitant sedation, and vasopressor therapy. Pregnant patients, patients in the peri-operative timeframe, and patients with acute coronary syndrome were excluded. Patients enrolled in the phase two pilot study received ketamine as the primary sedative. Ketamine was administered as a 1-2 mg/kg IV bolus, then as a continuous infusion starting at 5 mcg/kg/min, titrated 2 mcg/kg/min every 30 min as needed to obtain a Richmond Agitation Sedation Scale (RASS) goal of -1 to -2. If continuous sedation was still required after 48 h, patients were transitioned off ketamine and sedative strategy reverted to usual ICU sedation protocol. The primary outcome was the dose of vasopressor required at 24, 48, 72 and 96 h after enrollment. Secondary outcomes included cumulative ketamine dose, additional sedative and analgesics used, cumulative sedative and analgesic dosing at all time periods, corticosteroid use, days of mechanical ventilation, ICU LOS, hospital LOS, and mortality. Contiguous data were analyzed with unpaired t-tests and categorical data were analyzed with two-tailed, Fishers exact test. This study was approved by our Institutional Review Board. Results From January 2012 to April 2015, a total of 17 patients were enrolled. Patient characteristics were similar in the control and study group. Ketamine was discontinued in one patient due to agitation at 36 h. There was a trend towards decreased norepinephrine and vasopressin use in the study group at all time periods. Regarding secondary outcomes, the study group received less additional analgesia with fentanyl at 24 and 48 h (p < 0.001), and less additional sedation with lorazepam, midazolam or dexmedetomidine at 24 h (p = 0.015). Conclusion This pilot study demonstrated a trend towards decreased vasopressor dose, and decreased benzodiazepine and opiate use when ketamine is used as the sole sedative. The limitations to our study include a small sample size and those inherent in using a retrospective control group. Our findings should be further explored in a large, randomized prospective study.

Critical Care in the Military Health System: A Survey-Based Summary of Critical Care Services

Introduction Critical care is an important component of in-patient and combat casualty care, and it is a major contributor to U.S. healthcare costs. Regular exposure to critically ill and injured patients may directly contribute to wartime skills retention for military caregivers. Data describing critical care services in the Military Health System (MHS), however, is lacking. This study was undertaken to describe MHS critical care services, their resource utilization, and differences in care practices amongst military treatment facilities (MTFs). Materials and Methods Twenty-six MTFs representing 38 adult critical care services or intensive care units (ICUs) were surveyed. The survey collected information about organizational structure, resourcing, and unit characteristics at the time of a concurrent 24-h point-prevalence survey designed to describe patient characteristics and staffing in these facilities. The survey was anonymous and protected health information was not collected. We analyzed the data according to high capacity centers (HCCs) (≥200 beds) and low capacity centers (LCCs) (<200 beds). Differences between HCCs and LCCs were compared using Fishers exact test. Results Seventeen MTFs (7 HCCs and 10 LCCs), representing 27 ICUs, responded to the survey. This was a 65% response rate for MTFs and a 71% response rate for services/ICUs. HCCs reported more closed vs. open ICUs; more dedicated critical care services (i.e., medical and surgical ICUs vs. mixed ICUs); fewer respiratory therapists available, but more with certification; more total nursing staff and more critical care certified nurses; the use of subjectively more effective protocols (10.5 vs. 6.7 protocols/unit or service); higher utilization of an ICU daily rounds checklist (65% vs. 0%); and less consistency of clinician type participation during multidisciplinary rounds. ICU leadership structure was similar among the institutions. The majority of respondents were unable to provide summary APACHE II scores, but HCCs were more likely to submit this information than LCCs. Most centers perform multidisciplinary rounds daily, but they are more likely to be run by a physician credentialed in critical care at HCCs (85% vs. 59%, p < 0.05). 67% of respondents reported mortality rates <5%. The two services that reported mortality rates greater than 10% were both LCCs. Conclusion This is the first comprehensive report about MHS critical care services. Despite notable variability in data reporting, an important finding itself, this study highlights notable differences in organizational structure and resourcing between HCCs and LCCs within the MHS. The clinical implication of these differences (i.e., impact on patient outcomes) of these differences require further study. Better understanding of MHS critical care services may improve enterprise decision-making about these services which could ultimately improve care of combat casualties.

269: INDIRECT CALORIMETRY IS SUPERIOR TO PREDICTIVE EQUATIONS FOR ICU PATIENTS WITH PROLONGED STAY

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) in demographics or confounders. The 50–59% group achieved the highest rate of BG concentrations in goal range (68%) (P < 0.001). The 0–49% group, which was the transition method utilized most often, resulted in the lowest rate of goal achievement (46%). The rate of hypoglycemia was highest in the ≥ 80% group (6.9%), whereas the 50–59% and 60–69% group had no incidence (P = 0.015). The rate of hyperglycemia was highest in the 0–49% group (50%) and lowest in the 50–59% group (32%) (P < 0.001). Conclusions: Converting to 50–59% of the prior 24-hour IV insulin requirements was the safest and most effective transition method. A dosing protocol will be implemented to transition to 50–70% subcutaneous insulin. Follow-up data will be reviewed to assess the protocol’s safety and efficacy.