David M. Rothenberg

Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine.

T hese recommendations are intended to provide information and advice for clinicians who deliver end-of-life care in intensive care units (ICUs). The number of deaths that occur in the ICU after the withdrawal of life support is increasing, with one recent survey finding that 90% of patients who die in ICUs now do so after a decision to limit therapy (1). Although there is significant variability in the frequency of withdrawal of life support both within countries (2) and among cultures (3), the general trend is international in scope (4). Nevertheless, most evidence indicates that patients and families remain dissatisfied with the care they receive once a decision has been made to withdraw life support (5). Although intensive care clinicians traditionally have seen their goals as curing disease and restoring health and function, these goals must now expand when necessary to also include assuring patients of a “good death.” Just as developments in knowledge and technology have dramatically enhanced our ability to restore patients to health, similar developments now make it possible for almost all patients to have a death that is dignified and free from pain. The management of patients at the end of life can be divided into two phases. The first concerns the process of shared decision-making that leads from the pursuit of cure or recovery to the pursuit of comfort and freedom from pain. The second concerns the actions that are taken once this shift in goals has been made and focuses on both the humanistic and technical skills that must be enlisted to ensure that the needs of the patient and family are met. Although both of these issues are critically important in end-oflife care, the decision-making process is not unique to the ICU environment and has been addressed by others (6 –11). These recommendations, therefore, do not deal primarily with the process that leads to the decision to forego lifeprolonging treatments but rather focus on the implementation of that decision, with particular emphasis on the ICU environment. This division of the process into two phases is necessarily somewhat artificial. Patients and families do not suddenly switch from the hope for survival and cure to the acceptance of death and pursuit of comfort. This process happens gradually over varying periods of time ranging from hours to weeks. Similarly, the forgoing of life-sustaining treatments rarely happens all at once and is likewise a stepwise process that parallels the shift in goals. Although acknowledging the relationship between the process of decision-making and the corresponding actions, these guidelines will focus on the latter. These recommendations are written from the emerging perspective that palliative care and intensive care are not mutually exclusive options but rather should be coexistent (12–14). All intensive care patients are at an increased risk of mortality and can benefit from inclusion of the principles of palliative care in their management. The degree to which treatments are focused on cure vs. palliation depends on the clinical situation, but in principle both are always present to some degree. Figure 1 illustrates a useful paradigm for the integration of palliative care and curative care over the course of a patient’s illness. Although many patients are best served by transfer to other environments (e.g., home, hospice, or ward) that may be more conducive to palliative care, some patients are so dependent on ICU technology at the end of life that transfer is not possible. For those who are expected to survive for only a short time after the removal of life-sustaining technology, transfer of the patient to a new environment with new caregivers is awkward and may disrupt the patient’s medical care. For these reasons, among others, intensive care clinicians must become as skilled and knowledgeable at forgoing life-sustaining treatments as they are at delivering care aimed at survival and cure.

Efficacy of ephedrine in the prevention of postoperative nausea and vomiting.

Although reported in the aerospace literature and anecdotally by anesthesiologists, the putative antiemetic effect of ephedrine remains unquantitated. We therefore prospectively studied ephedrine as an antiemetic agent in the perioperative setting in 97 patients undergoing general anesthesia for outpatient gynecologic laparoscopy. Patients were assigned in a double-blind randomized fashion to receive a standardized general anesthetic followed by an intramuscular dose of either ephedrine (0.5 mg/kg), droperidol (0.04 mg/kg), or saline before the conclusion of surgery. Nausea, retching, or vomiting, as well as the degree of sedation and discharge times, were assessed in the recovery room and for 24 h postoperatively. Ephedrine was found to have a significantly antiemetic effect (P < 0.05) when compared with placebo and an antiemetic effect similar to that of droperidol. Sedation scores were also significantly less in the ephedrine group than in both placebo and droperidol groups. Finally, variations in mean arterial blood pressure among the three groups were not statistically significant. We conclude that ephedrine is an effective antiemetic agent with minimal sedative side effects in patients undergoing outpatient laparoscopy.

Neuro-Critical Care Skills Training Using a Human Patient Simulator

BackgroundNeurosurgical trainees regularly encounter critical care situations. Traditionally, education was accomplished through lecture and experience. Increasingly, human patient simulators (HPS) are employed, allowing trainees to sharpen skills in a safe and realistic environment. We describe our experience using HPS in neurosurgical training.MethodsWe developed a critical care training program for residents and medical students using HPS. We used a hi-fidelity, lifelike Human Patient Simulator™ (HPS™) produced by Medical Education Technologies, Inc.™ to simulate realistic scenarios for trainee education. Topics included spinal shock, closed head injury, and cerebral vasospasm. A three-way evaluation model was employed to test validity, including pre- and post-exercise testing, survey feedback, and videotaped replay. The simulation exercises were conducted by a neuro-critical care attending, a senior neurosurgical resident, and a HPS technician.ResultsWe currently have 29 participants. On a 20-point critical care multiple-choice exam for these participants, average improvement has been 4.5 points or 25%. In subgroup analysis, average improvement was 4.75 points (24%) amongst neurosurgery residents, 3.07 points (18%) amongst neurology residents, 7 points (38%) amongst general surgery residents, and 7 points (38%) amongst senior medical students. Post-exercise evaluations were overwhelmingly positive.ConclusionsNeurosurgical critical care education is important for safe and effective care for patients. Clinical experience and didactic lectures help trainees obtain a solid knowledge base, but do not provide the benefit for learning in a fail-safe environment. Through the use of HPS, we have enhanced the critical care education of our trainees.

Education of trainees in the intensive care unit

The focus on improving education in critical care medicine must begin early in medical school training and further be promoted during residency if there is to be an increase in intensivists in the hospital workforce. This is “critical” to healthcare reform movements that are endorsing full-time critical care coverage in U.S. urban intensive care units. There is, therefore, a need for more novel approaches in educating trainees in critical care medicine to better prepare future physicians to manage acutely ill patients and improve patient safety. This article will review methods to improve educational designs in teaching critical care medicine to medical students, residents, and fellows, including the use of simulation technology to enhance cognition and procedural skills.

Do-not-resuscitate orders in the presurgical patient

STUDY OBJECTIVE To assess the policy and practice of anesthesiology departments in regard to their management of the presurgical do-not-resuscitate (DNR) patient. DESIGN Questionnaire distributed to the program directors of 156 accredited residency programs in anesthesiology in the contiguous United States. SETTING University hospital. MEASUREMENTS AND MAIN RESULTS One hundred twelve of the 156 accredited U.S. programs responded to the questionnaire. The majority (81%) of programs that have a DNR policy for the presurgical patient suspend the order prior to surgery. However, only 50% of the institutions responding have standing policies, and of those that do not, only 40% plan to initiate such a policy. CONCLUSIONS The need for a written policy for the DNR patient undergoing surgery is exemplified by the low percentage of institutions that have existing policies.

Isotonic hyponatremia following transurethral prostate resection

The proper treatment of hyponatremia during transurethral resection of the prostate continues to be controversial. Two cases of isotonic hyponatremia are reported here, and the literature regarding the incidence and treatment of hyponatremia during transurethral resection of the prostate is reviewed. In each case, the patient developed neurologic changes during complicated transurethral prostate resection. Despite the rapid decrease in the serum sodium concentration, serum osmolality remained normal due to the resorption of the bladder irrigant glycine. Therefore, etiologies other than cerebral edema are postulated as the cause of the neurologic manifestations. Also, the role of the osmolar gap in directing appropriate therapy is emphasized in an effort to avoid unnecessary use of hypertonic saline. Finally, an appropriate differential diagnosis of the neurologic changes seen during the transurethral resection of the prostate syndrome is discussed.

Anesthesia and the Hepatobiliary System

• All volatile anesthetics decrease hepatic blood flow, but desflurane and sevoflurane have the least significant effect on total hepatic blood flow and hepatic oxygen delivery, whereas halothane induces the most profound reductions in hepatic blood flow. • Advanced liver disease may impair the elimination, prolong the half-life, and potentiate the clinical effects of several drugs, including morphine, meperidine, alfentanil, vecuronium, rocuronium, mivacurium, benzodiazepines, and dexmedetomidine. These drugs should be used cautiously in patients with cirrhosis or end-stage liver disease from any cause, and their dosage and administration should be adjusted accordingly. • Abnormal liver enzyme test results may be seen in up to 4% of normal individuals and up to 36% of psychiatric patients, although the prevalence of clinically significant hepatic dysfunction in these individuals is less than 1%, thus suggesting that further costly preoperative testing is unnecessary in asymptomatic patients. • Patients with asymptomatic elevations in serum transaminase levels (less than two times normal values) may undergo surgery with minimal impact on perioperative outcome. • Retrospective data suggest that patients with acute hepatitis from any cause are at increased risk for hepatic failure and death after elective surgery. Thus, elective surgery should be delayed in these individuals until resolution of acute hepatocellular dysfunction can be confirmed. • Asymptomatic patients with any form of chronic hepatitis should be carefully assessed before elective surgery, and meticulous care should be taken to maintain hepatic perfusion in the perioperative period and to avoid any hepatotoxic drugs or significant hypotension that could precipitate liver failure or hepatic encephalopathy. • Based on large retrospective studies, patients with cirrhosis who are undergoing abdominal surgery, especially those in Child-Turcotte-Pugh (CTP) class C, appear to have an increased risk of perioperative death. Elective surgery in these individuals should be avoided, if possible, in favor of less invasive procedures. • Postoperative jaundice may occur as a result of intraoperative hepatobiliary injury, anesthetic-induced hepatotoxicity, severe hepatic hypoperfusion (e.g., cardiogenic or hypovolemic shock), and a variety of medications. • Patients with the most advanced forms of liver disease (e.g., CTP class B or C cirrhosis) should receive management designed to maximize hepatic perfusion and hepatic oxygen delivery and to prevent and treat the complications of hepatic encephalopathy, cerebral edema, coagulopathy, hemorrhage, and portal hypertension.

The Effect of Esmolol Pretreatment on the Incidence of Regional Wall Motion Abnormalities During Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is associated with dramatic increases in arterial blood pressure and heart rate (HR) that may precipitate new left ventricular regional wall motion abnormalities (RWMAs) suggestive of myocardial ischemia.The purpose of this study was to investigate the effect of pretreatment with esmolol on the incidence of RWMAs after ECT. Thirteen patients served as their own controls and, in a random fashion, received a standard succinylcholine/methohexital anesthetic for one of two ECT sessions, and an identical anesthetic with esmolol 1 mg/kg for their other ECT session. Systolic (SBP), diastolic (DBP), mean arterial pressures (MAP) and HR were recorded after drug administration and before ECT and at 1-, 2-, 4-, 5-, 10-, and 15-min intervals after ECT. Echocardiograms were obtained at baseline, after drug administration, 1 min after ECT, and at recovery 15 min later. All patients had significant increases in SBP, DBP, and MAP at 1, 2, and 4 min after ECT versus baseline, whereas HR was significantly faster at all times in the control sessions. HR was significantly slower after anesthetic induction until 2 min after ECT in the esmolol versus the control group (P < 0.05). New RWMAs were seen in only 1 of 26 (4%) ECT sessions, despite the presence of baseline RWMAs in 31% of the patients. We conclude that contrary to previously reported data, new RWMAs after ECT are uncommon. Consequently, this study was unable to demonstrate any beneficial effect of pretreatment with esmolol on the incidence of ECT-induced RWMAs. (Anesth Analg 1996;82:143-7)

Unusual presentation of perioperative ischemic optic neuropathy following major spine surgery

Perioperative visual loss following spinal surgery has become of increasing concern among anesthesiologists, surgeons, and patients alike. Perioperative ischemic optic neuropathy often occurs in patients greater than 50 years of age, in association with a number of presumed risk factors, including diabetes, hypertension, small cup-to-disc ratio, preoperative anemia, intraoperative hypotension, prolonged operative time in the prone position, and significant blood loss during surgery. The visual loss is notably devastating, and generally leads to permanent disability. A 44-year-old man whose central visual acuity was completely preserved is presented.

Pulmonary artery catheter: what does the literature actually tell us?

Since its introduction to clinical medicine 30 years ago, the pulmonary artery catheter (PAC) has been commonly used to detect and monitor hemodynamic aberrations in both the critically ill and high-risk surgical patient. Despite widespread clinical acceptance, continued controversy remains about whether the data obtained from this device impact in a positive manner on patient well-being and outcome. In 1996 this controversy escalated when results of a multicenter, observational study suggested that PAC placement in critically ill patients was associated with both an increased utilization of resources and mortality. An accompanying editorial recommended that the National Heart, Lung, and Blood Institute (NHLBI) commence a multicenter, randomized, controlled study to determine the efficacy of the PAC or, if not possible, to have the Food and Drug Administration (FDA) issue a moratorium on its further use. The medical community responded with a litany of letters and editorials and the formation of expert consensus panels, most criticizing the methodology and results of the original article or the reactionary response of the editorial. Still, had the PAC been initially introduced to clinical practice in the 21st century, and therefore likely subjected to the methodological scrutiny of “evidence-based” medicine and to rigid cost/benefit analysis, would it have been so universally embraced? Would there not have been the adoption of stringent guidelines detailing clinical indications for PAC use? Would not clinicians have been required to undergo mandatory credentialing, based on both performance of PAC insertion and data interpretation? Seeking to address these questions, we assess what the literature actually says about the PAC, the data this device provides, our ability as clinicians to interpret these data, as well as its inherent risks and its ultimate benefits, if any, to the patient.