David Kaufman

Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine

Background:These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. Principal Findings:Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient’s death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. Conclusions:End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.

Guidelines for intensive care unit design.

Objective: To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit. Participants: A group of multidisciplinary professionals, designers, and architects with expertise in critical care, under the direction of the American College of Critical Care Medicine, met over several years, reviewed the available literature, and collated their expert opinions on recommendations for the optimal design of an intensive care unit. Scope: The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare architects have experience in this process that most healthcare professionals do not. While there are regulatory documents, such as the Guidelines for the Design and Construction of Health Care Facilities, these represent minimal guidelines. The intent was to develop recommendations for a more optimal approach for a healing environment. Data Sources and Synthesis: Relevant literature was accessed and reviewed, and expert opinion was sought from the committee members and outside experts. Evidence-based architecture is just in its beginning, which made the grading of literature difficult, and so it was not attempted. The previous designs of the winners of the American Institute of Architects, American Association of Critical Care Nurses, and Society of Critical Care Medicine Intensive Care Unit Design Award were used as a reference. Collaboratively and meeting repeatedly, both in person and by teleconference, the task force met to construct these recommendations. Conclusions: Recommendations for the design of intensive care units, expanding on regulatory guidelines and providing the best possible healing environment, and an efficient and cost-effective workplace. (Crit Care Med 2012; 40:–16)

Cytochrome P450 3A4 activity after surgical stress

ObjectiveTo evaluate the relationship between the acute inflammatory response after surgical trauma and changes in hepatic cytochrome P450 3A4 activity, compare changes in cytochrome P450 3A4 activity after procedures with varying degrees of surgical stress, and to explore the time course of any potential drug-cytokine interaction after surgery. DesignProspective, open-label study with each patient serving as his or her own control. SettingUniversity-affiliated, acute care, general hospital. PatientsA total of 16 patients scheduled for elective repair of an abdominal aortic aneurysm (n = 5), complete or partial colectomy (n = 6), or peripheral vascular surgery with graft (n = 5). InterventionsCytochrome P450 3A4 activity was estimated using the carbon-14 [14C]erythromycin breath test (ERMBT) before surgery and 24, 48, and 72 hrs after surgery. Abdominal aortic aneurysm and colectomy patients also had an ERMBT performed at discharge. Blood samples were obtained before surgery, immediately after surgery, and 6, 24, 32, 48, and 72 hrs after surgery for determination of plasma concentrations of interleukin-6, interleukin-1&bgr;, and tumor necrosis factor-&agr;. Clinical markers of surgical stress that were collected included duration of surgery, estimated blood loss, and volume of fluids administered in the operating room. Measurements and Main ResultsERMBT results significantly declined in all three surgical groups, with the lowest value at the time of the 72-hr study in all three groups. There was a trend toward differences in ERMBT results among groups that did not reach statistical significance (p = .06). The nadir ERMBT result was significantly and negatively correlated with both peak interleukin-6 concentration (rs = −.541, p = .03) and log interleukin-6 area under the curve from 0 to 72 hrs (rs = −.597, p = .014). Subjects with a peak interleukin-6 of >100 pg/mL had a significantly lower nadir ERMBT compared with subjects with a peak interleukin-6 of <100 pg/mL (35.5% ± 5.2% vs. 74.7% ± 5.1%, p < .001). ConclusionsAcute inflammation after elective surgery was associated with a significant decline in cytochrome P450 3A4 activity, which is predictive of clinically important changes in the metabolism of commonly used drugs that are substrates for this enzyme.

A Prospective Evaluation of Propylene Glycol Clearance and Accumulation During Continuous-Infusion Lorazepam in Critically Ill Patients

Propylene glycol is a commonly used diluent in several pharmaceutical preparations, including the sedative lorazepam. Fifty critically ill patients receiving continuous-infusion lorazepam for a minimum of 36 hours were prospectively evaluated to determine the extent of propylene glycol accumulation over time, characterize propylene glycol clearance in the presence of critical illness, and develop a pharmacokinetic model that would predict clearance based on patient-specific clinical, laboratory, and demographic factors. In this cohort, the median lorazepam infusion rate was 2.1 mg/h (0.5-18). Propylene glycol concentration correlated poorly with osmolality, osmol gap, and lactate. In all, 8 patients (16%) had significant propylene glycol accumulation (>25mg/dL). When propylene glycol concentrations were >25 mg/dL, the median lorazepam infusion rate before sample collection was higher, 6.4 (1.9-11.3) versus 2.0 (0.5-7.4) mg/h (P =.0003). A linear first-order model with interoccasion variability on clearance adjusted for total body weight and Acute Physiology and Chronic Health Evaluation II score predicted propylene glycol concentration.

Osmolality of Commonly Used Medications and Formulas in the Neonatal Intensive Care Unit

The objective of the study was to measure the osmolality of medications and special infant formulas commonly used in contemporary neonatal intensive care units. The osmolalities of 75 medications and 20 infant formulas were determined in triplicate by freezing point depression, and the means were reported. A majority of the medications (54 of 75) analyzed had a measured osmolality in excess of 2000 mOsm/kg. Most infant formulas possessed an osmolality within American Academy of Pediatrics (AAP) recommendations (400 mOsm/L), with the exception of powder-fortified human milk and a protein hydrolysate formula concentrated to 30mL. Final osmolality of infant feedings should be measured or calculated when medications are added and when calories are concentrated beyond 24 kcal/oz. Oral administration of medications, powdered fortification of human milk, and the concentration of some infant formulas may potentiate adverse gastrointestinal effects associated with hyperosmolar feedings and should be postponed unti...

Pay for performance in critical care: An executive summary of the position paper by the Society of Critical Care Medicine

Concerns over the rising costs and quality of U.S. healthcare have led to interest in a performance-based approach. In a comparison of healthcare delivery in 191 countries, the United States ranked 37 in performance while expending the highest portion of gross domestic product on healthcare. Reimbursement for healthcare in the United States has been based primarily on quantity rather than quality. A “pay-for-performance” (P4P) approach has been suggested as a method to align incentives so that hospitals and providers are encouraged to deliver highquality care in a more cost-effective and efficient manner. Understanding the strengths and weaknesses of a P4P system is essential for all aspects of the healthcare system. The Society of Critical Care Medicine (SCCM) and other national organizations must understand these changes and become involved in the developmental aspects to support their members. The Pay-For-Performance Task Force was created by the SCCM to address these issues. This paper, a work product of that task force, serves as a brief primer on the current status of the P4P movement in the United States as it relates to critical care services. A fulllength task force report is available to SCCM members at www.sccm.org.

Effects of metronidazole on hepatic CYP3A4 activity.

Study Objective. To evaluate the effect of a short course of oral metronidazole, commonly used for bowel‐preparation regimens, on hepatic cytochrome P450 (CYP) 3A4 activity, as measured by the [14C N‐methyl]‐erythromycin breath test (ERMBT) in healthy volunteers.

Relative Bioavailability of Orally Administered Fosphenytoin Sodium Injection Compared with Phenytoin Sodium Injection in Healthy Volunteers

To describe the pharmacokinetics of fosphenytoin (FPHT) sodium injection when administered orally, and to determine the relative oral bioavailability (FREL) of FPHT sodium injection compared with PHT sodium injection based on pharmacokinetic modeling in healthy volunteers.

TIPS performed in a patient with complete portal vein thrombosis

Portal vein thrombosis is common in cirrhotic patients and results in increased morbidity and mortality. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a well-established therapy for refractory variceal bleeding and refractory ascites in patients who do not tolerate repeated large volume paracentesis. Experience and technical improvements have led to improved TIPS outcomes that have encouraged an expanded application. Complete portal vein thrombosis has come a long way from being a contraindication to an indication for TIPS procedure. As experience and technology have evolved, the ultrasound guidance transvenous access of portal vein from the hepatic vein help in overall higher success rate of performing the TIPS procedure and reducing the procedure-related complications.

Adjustment of Nutrition Support With Continuous Hemodiafiltration in a Critically Ill Patient

Glucose-containing dialysis solutions are commonly used for continuous renal replacement therapy. A significant portion of this glucose is transferred across the dialysis membrane, which necessitates a change in the carbohydrates being provided by alternative nutrition support. Glucose transfer usually is estimated empirically, but glucose absorption across a dialysis membrane can be measured easily during continuous dialysis because the quantity of glucose from the patient (Gluₒᵤₜ. BFR [blood flow rate]) plus the quantity that is absorbed across the dialysis membrane (Gluₐddₑd) must be equal to the quantity going back to the patient (Gluᵢₙ. BFR): Gluₐddₑd = (Gluᵢₙ - Gluₒᵤₜ) X BFR X k, where k is a conversion factor to correct for different units. This teaching case describes the course of an 83-year-old man receiving continuous dialysis, for whom adjustments to his nutrition support were made on multiple occasions on the basis of direct measurement of the amount of glucose absorbed from the dialysis solution. The described method is easy to apply at the bedside and should allow for appropriate prescription of carbohydrate calories during continuous dialysis when glucose-containing solutions are used.