Frederick J. Curley

Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation

ObjectiveTo examine the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide, quality improvement program on clinical and economic outcomes. DesignProspective, before-and-after intervention study. Data from a preimplementation year are compared with those of the first 2 yrs after protocol implementation. Patients and SettingPatients older than 18 yrs in diagnosis-related group 475 and group 483, who were admitted to the adult medical, surgical, and cardiac intensive care units (ICU) in a university hospital. InterventionsAfter the baseline year, a weaning management program was implemented throughout our institution. Primary endpoints were mortality, days on mechanical ventilation, ICU and hospital lengths of stay, hospital costs, and the percentage of patients requiring tracheostomy. Main ResultsThe number of patients increased from 220 in the baseline year (year 0) to 247 in the first year (year 1), then to 267 in the second year (year 2). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score increased from 22.2 to 24.4 in year 1 (p = .006) and to 26.2 in year 2 (p < .0005). When year 0 was compared with year 1, mean days on mechanical ventilation decreased from 23.9 to 21.9 days (p = .608), hospital length of stay decreased from 37.5 to 31.6 days (p = .058), ICU length of stay decreased from 30.5 to 25.9 days (p = .133), and total cost per case decreased from

Accuracy of 30-Minute Indirect Calorimetry Studies in Predicting 24-Hour Energy Expenditure in Mechanically Ventilated, Critically Ill Patients

92,933 to

Appropriate use of antitussives and protussives. A practical review.

78,624 (p = .061). When year 0 was compared with year 2, mean days on mechanical ventilation decreased from 23.9 days to 17.5 days (p = .004), mean hospital length of stay decreased from 37.5 to 24.7 days, mean ICU length of stay decreased from 30.5 to 20.3 days, total cost per case decreased from

Gas Embolism: Part I. Venous Gas Emboli

92,933 to

Hypothermia: A Critical Problem in the Intensive Care Unit

63,687, and percentage of patients requiring tracheotomy decreased from 61% to 41% (all p < .0005). There was also a reduction in the percentage of patients requiring more than one course of mechanical ventilation during the hospitalization from 33% to 26% (p = .039), a total cost savings of

Analytic Review: Disorders of Temperature Control: Part I. Hyperthermia:

3,440,787 and a decrease in mortality between all 3 yrs from 32% to 28% (p = .062). ConclusionsA multifaceted, multidisciplinary weaning management program can change the process of care used for weaning patients from mechanical ventilation throughout an acute care hospital and across multiple services. This change can lead to large reductions in the duration of mechanical ventilation, length of stay, and hospital costs, even at a time when patients are sicker.

Disorders of Temperature Control: Hyperthermia, Part II

BACKGROUND There is no consensus regarding the optimal duration of measurement or time of day to perform indirect calorimetry (IC). Energy expenditure (EE) varies at different times of day and with different activity levels. We sought to assess the variability of EE in mechanically ventilated patients over a 24-hour period and the accuracy of 30-minute IC studies in predicting the 24-hour energy expenditure (EE24). METHODS The study was a prospective comparison between the resting EE obtained by 30-minute measurement of IC and EE values obtained from 24-hour measurements. Tests were performed in the Medical Intensive Care Unit (MICU) of a tertiary care, university hospital. Oxygen consumption (VO2) and carbon dioxide production (VCO2) were measured for 24 hours in eight ventilated patients. Measurements were made every 3 minutes and used to calculate 30-minute and 24-hour oxygen consumption values. EE24 was calculated using the modified Weir equation. Each 30-minute interval was compared with the value obtained from the 24-hour measurement. RESULTS Three hundred forty-one of 384 30-minute intervals remained for analysis. Average EE24 measured was 1490 +/- 486 kcal/d. Average EE24 predicted by extrapolation from 30-minute studies was 1501 +/- 503 kcal/d, with a mean difference of 0 +/- 209 kcal/d from the measured 24-hour values (range: -1068 to +585 kcal/d). Thirty-minute studies were within 20% of 24-hour measurements for 89% of intervals. The difference between 24-hour and 30-minute studies correlated with changes in minute ventilation (VE), heart rate, systolic blood pressure, and breath rate from their 24-hour means (p < .001). The mean error of EE estimate was greatest between 3 and 11 PM (p < .001). CONCLUSIONS We conclude the following: (1) EE in MICU patients is variable; (2) 30-minute IC studies predict measured EE24 acceptably well for clinical purposes; and (3) accuracy is maximized if a 30-minute study is performed between 11 PM and 3 PM, and when Ve, heart rate, systolic blood pressure, and breath rate are near the days average.

Indications for and Complications of Rectal Tube Use in Critically Ill Patients

SummaryAs a symptom of an underlying condition, cough is one of the most common reasons patients see physicians. To the majority, a cough means that ‘something is wrong’ and it causes exhaustion and/or self-consciousness. Patients find these reasons as well as effects on lifestyle, fear of cancer and/or AIDS or tuberculosis to be the most troublesome concerns for which they seek medical attention.The treatment of cough can be divided into two main categories: (a) therapy that controls, prevents or eliminates cough (i.e. antitussive); and (b) therapy that makes cough more effective (i.e. protussive).Antitussive therapy can be either specific or nonspecific. Definitive or specific antitussive therapy depends on determining the aetiology or operant pathophysiological mechanism, and then initiating specific treatment. Since the cause of chronic cough can almost always be determined, it is possible to prescribe specific therapy that can be almost uniformly successful. Nonspecific antitussive therapy is directed at the symptom; it is indicated when definitive therapy cannot be given. Practically speaking, the efficacy of nonspecific therapy must be evaluated in double-blind, placebo-controlled, randomised studies of pathological cough in humans.Such studies have demonstrated the efficacy of dextromethorphan, codeine and ipratropium bromide aerosol in patients with chronic bronchitis. While the preferred treatment for patients with cough due to angiotensin converting enzyme (ACE) inhibitor therapy is withdrawal of the offending drugs, it may be possible to ameliorate the cough by adding nifedipine, sulindac or indomethacin to the treatment regimen.The efficacy of protussive therapy has not been well documented. Although hypertonic saline aerosol and erdosteine in patients with bronchitis, and amiloride aerosol in patients with cystic fibrosis have been shown to improve mucus clearance, their clinical utility has not been adequately studied.

Gas Embolism: Part II. Arterial Gas Embolism and Decompression Sickness

Gas emboli syndromes occur in many different settings, and their medical significance ranges from being life-threatening emergencies to being totally innocuous. We discuss venous gas embolization in Part I of this review, and it can result from a variety of traumatic, diagnostic, therapeutic, and surgical interventions. The pathophysiological consequences depend on where the gas bubbles impact and obstruct the circulation—by creating an “air lock” in the right ventricle, by obstruction of pulmonary arterioles, and sometimes with passage into the arterial circulation (so called paradoxical emboli). Various monitoring techniques are available and are known to be useful in high-risk patients. Nevertheless, the diagnosis can be difficult to establish. Myriad and generally nonspecific clinical manifestations may be present; the patient may often exhibit signs and symptoms suggestive of other acute cardiopulmonary or central nervous system events. The classically described “mill-wheel murmur” is actually a rare finding, and it is transient at best. There are no specific diagnostic tests available, and clinicians, must depend on a high level of suspicion in the appropriate settings. Rapid identification of the problem, with prevention of further gas entry into the venous circulation, should be a routine measure. The left lateral decubitus position, administration of 100% oxygen, and hyperbaric oxygenation should all be considered, and they have been shown to be effective treatment modalities.

Routine Monitoring of Critically I11 Patients

Hypothermia (Le., core temperature < 35°C) occurs commonly. Although the reported mortality rate for hypothermia has been conservatively estimated at 17 deaths per million per year in the United States, most authorities agree that hypothermia is frequently missed and underreported [11. Numerous publications now strongly support that hypothermia is a yearround, common occurrence in Emergency Departments (EDs) and Post-Anesthesia Care Units (PACUs) (2). In the. ED, hypothermia frequently results from exposure, drug or alcohol use, hypoglycemia, or trauma. Even healthy, young individuals exposed to mild, cool weather on a windy, rainy day may easily become hypothermic. Although everyone is at risk for hypothermia, in some series up to 91%of hypothermia in the ED setting is due to drugs or alcohol (3), Up to 42% of patients with moderate trauma experience hypothermia on the first day of hospital admission (4). Many of these patients seen in the ED setting require urgent surgery, and they remain hypothermic on admission to the PACU. Hypothermia frequently develops intraoperatively and postoperatively in patients who are normothermic prior to surgery due to the decreased heat production associated with paralysis and anesthesia, coupled with the increased heat loss from exposed body cavities in cool operating rooms. Temperatures below 35°C develop perioperatively in 13% of patients undergoing elective surgery [5). Although hypothermia in intensive care units (lCU) is less well studied, virtually all the patients seen in EDs or PACUs are eventually cared for in the ICU. Hypothermia may also develop in other ICU patients as a result of sedation, paralysis, hypoglycemia, myxedema, stroke, burns, or other skin disorders [2]. Review of an APACHE II database from my institution indicates that 3.2% of patients in medical and surgical ICUs experience hypothermia within 48 hours of admission. It can be easily argued that busy intensive care physicians in any type ofIeD see at least 1 hypothermic patient per week. The mortality from hypothermia is high. Although most agree that moderate hypothermia of almost any cause if left untreated will be almost universally fatal, the mortality rate for treated hypothermia ranges from 12 to 73% [6,7). Mortality varies with the severity of the underlying disease and the initial body temperature. In mountain climbers suffering exposure, mortality is 25% for temperatures above 32°C and 66% for temperatures below 27°C (8). The overall mortality rate of hypothermic ED patients is only 12%, but it climbs to 50% if serious underlying disease is present (7). The independent contribution of hypothermia to ICU mortality has been recognized in all the APACHE scoring systems. Despite recognition of the prevalence and morbidity of hypothermia in the medical literature, hypothermia remains under-recognized, and treatment regimens for hypothermia remain both understudied and controversial. In a retrospective review of ICU care for hypothermic patients 25% of hypothermia went untreated by the ICU staff, and, when treated, treatment was not initiated for an average of 4 hours after hypothermia was identified [9]. Treatment for hypothermia usually consists of treating the underlying cause of the hypothermia and rewarming. Identifying the underlying cause of hypothermia can usually be achieved by history, physical examination, and a small number of laboratory tests (2). However, there is little consensus as to the best way to rewarm patients because (1) the desired speed of rewarming may vary with the severity of the hypothermia and the underlying cause, (2) most studies that have evaluated rewarming protocols have done so on small groups of poorly characterized patients in a nonrandomized, uncontrolled fashion, and (3) the best technique may vary depending on the point of care-what is best on the mountainside may not be so in a PACU. In this issue, Gentilello and Moujaes provide an elegant thermodynamic description of rewarming. By using fundamental scientific principles regarding heat transfer and by relying on estimates of the heat transfer characteristics of body tissues, they developed a mathematical model of heat flux that permits formation of some generalizations about rewarming. They apply classic thermodynamic approaches traditionally used to discuss temperature regulation in normal individuals [10,11) in such a way as to model rewarming in ill patients. They provide sufficient comparisons to real patient data to support their hypothesis that the model actually characterizes rewarming well. Although the thermodynamic properties of individual patients may vary due to percentage of body fat, size, and cardiac output, the model provides an excellent method for making generalizations and comparisons. The average rates of rewarming for different methods of rewarming are shown to depend on the fundamental differences in the thermodynamics involved with each method.