Jorge A. Guzman

A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia.

Objectives:To compare usual care with a proactive case-finding approach for critically ill patients with terminal dementia using an inpatient palliative care service. Design:Prospective comparison to historical control. Setting:Urban, university-affiliated hospital. Patients:Total of 52 men and women with end-stage dementia, 26 subjects in each control and intervention group. Interventions:Proactive case-finding by the palliative care service was done to offer early assistance to the intensive care unit staff about the treatment of patients with terminal dementia. Results were compared with data obtained retrospectively. Measurements and Main Results:Measurements included age, gender, Acute Physiology and Chronic Health Evaluation Score, Therapeutic Intervention Scoring System, mortality, intensive care unit and hospital lengths of stay, frequency, timing, and goals of do-not-resuscitate orders. The proactive, case-finding approach decreased hospital and medical intensive care unit length of stay. More important, a proactive palliative intervention decreased the time between identification of the poor prognosis and the establishment of do-not-resuscitate goals, decreased the time terminal demented patients remained in the intensive care unit, and reduced the use of nonbeneficial resources, thus reducing patient burden and the cost of care while having the potential to afford the patient and family increased comfort and psychoemotional support. Conclusions:Proactive interventions from a palliative care consultant within this subset of patients improved end-of-life care and decreased use of superfluous resources.

Arterial blood pressure monitoring in overweight critically ill patients: invasive or noninvasive?

IntroductionBlood pressure measurements frequently guide management in critical care. Direct readings, commonly from a major artery, are considered to be the gold standard. Because arterial cannulation is associated with risks, alternative noninvasive blood pressure (NIBP) measurements are routinely used. However, the accuracy of NIBP determinations in overweight patients in the outpatient setting is variable, and little is known about critically ill patients. This prospective, observational study was performed to compare direct intra-arterial blood pressure (IABP) with NIBP measurements obtained using auscultatory and oscillometric methods in overweight patients admitted to our medical intensive care unit.MethodAdult critically ill patients with a body mass index (BMI) of 25 kg/m2 or greater and a functional arterial line (assessed using the rapid flush test) were enrolled in the study. IABP measurements were compared with those obtained noninvasively. A calibrated aneroid manometer (auscultatory technique) with arm cuffs compatible with arm sizes and a NIBP monitor (oscillometric technique) were used for NIBP measurements. Agreement between methods was assessed using Bland-Altman analysis.ResultsFifty-four patients (23 males) with a mean (± standard error) age of 57 ± 3 years were studied. The mean BMI was 34.0 ± 1.4 kg/m2. Mean arm circumference was 32 ± 0.6 cm. IABP readings were obtained from the radial artery in all patients. Only eight patients were receiving vasoactive medications. Mean overall biases for the auscultatory and oscillometric techniques were 4.1 ± 1.9 and -8.0 ± 1.7 mmHg, respectively (P < 0.0001), with wide limits of agreement. The overestimation of blood pressure using the auscultatory technique was more important in patients with a BMI of 30 kg/m2 or greater. In hypertensive patients both NIBP methods underestimated blood pressure as determined using direct IABP measurement.ConclusionOscillometric blood pressure measurements underestimated IABP readings regardless of patient BMI. Auscultatory measurements were also inaccurate, tending to underestimate systolic blood pressure and overestimate mean arterial and diastolic blood pressure. NIBP can be inaccurate among overweight critically ill patients and lead to erroneous interpretations of blood pressure.

Relationship between systemic oxygen supply dependency and gastric intramucosal PCO2 during progressive hemorrhage.

BACKGROUND As systemic oxygen delivery (DO2) is reduced, oxygen consumption (VO2) is maintained until a critical level is reached (DO2crit) below which VO2 becomes supply-dependent and anaerobic metabolism ensues. We examined the relationship between gastric intramucosal PCO2 (PiCO2) and the onset of systemic supply dependency. We also compared PiCO2 to mixed venous and portal venous blood PCO2 (PmvCO2 and PpvCO2) to assess their utility as premonitory indicators of supply dependency. METHODS Six dogs were subjected to stepwise hemorrhage to effect a progressive decrease in DO2. Inflection points for changes in VO2, PiCO2, PmvCO2, and PpvCO2 versus DO2 were determined. RESULTS Mean DO2crit was 6.0 +/- 0.7 mL x kg(-1) x min(-1), whereas the DO2 at which inflection points occurred for PiCO2 and PpvCO2 were 13.2 +/- 1.4 and 11.2 +/- 1.5 mL x kg(-1) x min(-1), respectively (p < 0.05 for both). CONCLUSION Continuous monitoring of PiCO2 using capnometric recirculating gas tonometry can serve as an early indicator of systemic hypoperfusion before the onset of systemic supply dependency.

Hypophosphatemia during continuous hemodialysis is associated with prolonged respiratory failure in patients with acute kidney injury

BACKGROUND Hypophosphatemia is common in critically ill patients and has been associated with generalized muscle weakness, ventilatory failure and myocardial dysfunction. Continuous renal replacement therapy causes phosphate depletion, particularly with prolonged and intensive therapy. In a prospective observational cohort of critically ill patients with acute kidney injury (AKI), we examined the incidence of hypophosphatemia during dialysis, associated risk factors and its relationship with prolonged respiratory failure and 28-day mortality. METHODS This is a single-center prospective observational study. Included in the study were 321 patients with AKI on continuous dialysis as initial treatment modality. RESULTS Four per cent of the patients had a phosphate level <2 mg/dL at initiation and 27% during dialysis. Low baseline phosphate was associated with older age, female gender, parenteral nutrition, vasopressor support, low calcium, and high urea, bilirubin and creatinine, whereas hypophosphatemia during dialysis correlated with the ischemic acute tubular necrosis etiology of renal failure, intensive dose and longer therapy. Serum phosphate decline during dialysis was associated with higher incidence of prolonged respiratory failure requiring tracheostomy [odds ratio (OR) = 1.81; 95% confidence interval (CI) = 1.07-3.08], but not 28-day mortality (OR = 1.16; 95% CI = 0.76-1.77) in multivariable analysis. CONCLUSIONS Hypophosphatemia occurs frequently during dialysis, particularly with long and intensive treatment. Decline in serum phosphate levels during dialysis is associated with higher incidence of prolonged respiratory failure requiring tracheostomy, but not 28-day mortality.

Carbon Monoxide Poisoning

Carbon monoxide (CO) poisoning is the leading cause of death as a result of unintentional poisoning in the United States. CO toxicity is the result of a combination of tissue hypoxia-ischemia secondary to carboxyhemoglobin formation and direct CO-mediated damage at a cellular level. Presenting symptoms are mostly nonspecific and depend on the duration of exposure and levels of CO. Diagnosis is made by prompt measurement of carboxyhemoglobin levels. Treatment consists of the patients removal from the source of exposure and the immediate administration of 100% supplemental oxygen in addition to aggressive supportive measures. The use of hyperbaric oxygen is controversial.

Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program.

OBJECTIVE To evaluate the effects of an active surveillance program for Staphylococcus aureus linked to a decolonization protocol on the incidence of healthcare-associated infection and new nasal colonization due to S. aureus. DESIGN Retrospective quasi-experimental study. SETTING An 18-bed medical intensive care unit at a tertiary care center in Cleveland, Ohio. METHODS From January 1, 2006, through December 31, 2007, all patients in the medical intensive care unit were screened for S. aureus nasal carriage at admission and weekly thereafter. During the preintervention period, January 1 through September 30, 2006, only surveillance occurred. During the intervention period, January 1 through December 31, 2007, S. aureus carriers received mupirocin intranasally. Beginning in February 2007, carriers also received chlorhexidine gluconate baths. RESULTS During the preintervention period, 604 (73.7%) of 819 patients were screened for S. aureus nasal carriage, yielding 248 prevalent carriers (30.3%). During the intervention period, 752 (78.3%) of 960 patients were screened, yielding 276 carriers (28.8%). The incidence of S. aureus carriage decreased from 25 cases in 3,982 patient-days (6.28 cases per 1,000 patient-days) before intervention to 18 cases in 5,415 patient-days (3.32 cases per 1,000 patient-days) (P=.04; relative risk [RR], 0.53 [95% confidence interval {CI}, 0.28-0.97]) and from 9.57 to 4.77 cases per 1,000 at-risk patient-days (P=.02; RR, 0.50 [95% CI, 0.27-0.91]). The incidence of S. aureus hospital-acquired bloodstream infection during the 2 periods was 2.01 and 1.11 cases per 1,000 patient-days, respectively (P=.28). The incidence of S. aureus ventilator-associated pneumonia decreased from 1.51 to 0.18 cases per 1,000 patient-days (P=.03; RR, 0.12 [95% CI, 0.01-0.83]). The total incidence of S. aureus hospital-acquired infection decreased from 3.52 to 1.29 cases per 1,000 patient-days (P=.03; RR, 0.37 [95% CI, 0.14-0.90]). CONCLUSIONS Active surveillance for S. aureus nasal carriage combined with decolonization was associated with a decreased incidence of S. aureus colonization and hospital-acquired infection.

Caring for VIPs: Nine principles

Caring for very important persons (VIPs), including celebrities and royalty, presents medical, organizational, and administrative challenges, often referred to collectively as the “VIP syndrome.” The situation often pressures the health care team to bend the rules by which they usually practice medicine. Caring for VIP patients requires innovative solutions so that their VIP status does not adversely affect the care they receive. We offer nine guiding principles in caring for VIP patients. When the patient is a “very important person,” the health care team should resist pressure to bend the rules.

Septic Shock Due to Candidemia: Outcomes and Predictors of Shock Development

Background The present report describes the outcomes of a cohort of patients with Candida induced septic shock. Methods Retrospective analysis of individuals who had at least one positive blood culture for Candida species ≥ 48 h after ICU admission. Data from patients that developed septic shock within 48 hr of the positive blood culture were compared to non-shock candidemic patients. Patients with a concomitant bacteremia and/or endocarditis were excluded. Results Fifteen patients with Candida induced septic shock were studied and compared to 35 candidemic patients without shock. Overall mortality was 76% (87 % among those who had shock). A high proportion of non-albicans Candida species causing fungemia (74%) was observed. All patients with shock were receiving antibiotics but not antifungal treatment at the time of shock development, eight were on parenteral nutrition, six on steroids and nine had a cancer history. High dose fluconazole was the most common initial treatment provided. Four patients died before receiving any antifungal treatment. Time in ICU before the development of candidemia was identified as a predictor of shock development (higher chance if fungemia developed < 7 days after ICU admission). Conclusions Septic shock due to invasive candidiasis is a near fatal condition. No conventional risk factors were identified to predict shock development other than time (shorter) spent in ICU before the development of candidemia. We encourage clinicians to consider the initiation of appropriate empiric antifungal treatment in high-risk patients who develop septic shock while on antimicrobial treatment. Keywords Septic shock; Candidemia; Outcome; Predictor

End-tidal partial pressure of carbon dioxide as a noninvasive indicator of systemic oxygen supply dependency during hemorrhagic shock and resuscitation.

&NA; When oxygen delivery (Do2) critically decreases, oxygen consumption (Vo2) becomes supply dependent. We examined whether end‐tidal Pco2 (Petco2) would identify supply dependency during shock. Five dogs (Group I) underwent progressive hemorrhage to decrease Do2 until they could no longer maintain a stable blood pressure. Five additional animals (Group II) were bled until Vo2 decreased to 70% of baseline, followed by resuscitation. The Petco2 versus time inflection point was compared with the Do2 at onset of supply dependency (Do2crit). Do2crit for Groups I and II were 6.9 ± .4 and 8.1 ± 1.3, respectively (p = NS), and not statistically different from the Do2 values at which Petco2 decreased (6.6 ± .7 and 6.3 ± .7 mL/kg per min, respectively). At constant minute volume, Petco2 effectively indicated the onset of supply dependency and rapidly increased during resuscitation, paralleling the changes in Vo2 in this model of hemorrhagic shock.

Gut mucosal-arterial Pco2 gradient as an indicator of splanchnic perfusion during systemic hypo- and hypercapnia

OBJECTIVES By accounting for influences of systemic acid-base disturbances, gut mucosal-arterial Pco2 gradient (Pico2 - Paco2) has been increasingly advocated as a more specific marker of splanchnic perfusion than Pico2 alone. We examined the stability of the Pico2 - Paco2 gradient compared with raw Pico2 measurements during induced systemic hypo- and hypercapnia. DESIGN A prospective animal study. SETTINGS A university research laboratory. SUBJECTS Twenty anesthetized, paralyzed, and mechanically ventilated mongrel dogs. INTERVENTIONS After a baseline period during which Paco2 was maintained near 40 torr, the animals were divided into four groups. Minute ventilation was then altered by adjusting tidal volume, frequency, or both to achieve group Paco2 values of 15, 20, 60, and 80 torr for groups 1 through 4, respectively. Portal blood flow was monitored and maintained near baseline levels by infusion of intravenous fluids. Intestinal Pico2 was measured continuously by using capnometric recirculating gas tonometry. MEASUREMENTS AND MAIN RESULTS Mean (+/- SE) aggregate baseline Pico2 - Paco2 was 16.9+/-3.3 torr. After 60 mins of hypoventilation, Pico2 - Paco2 decreased to 14.2+/-1.1 and to 13.7+/-2.7 torr in groups 3 and 4, respectively (p = NS, compared with baseline for both). On the other hand, after 60 mins of hyperventilation, Pico2 - Paco2 increased to 37.9+/-3.6 and 28.0+/-6.3 torr in groups 1 and 2, respectively (p < .0001, compared with baseline for both). CONCLUSIONS In this model of maintained portal blood flow, Pico2 - Paco2 remained essentially stable after hypoventilation but increased significantly after inducing hyperventilation. Our findings warrant cautious interpretation of Pico2 - Paco2 as an indicator of splanchnic perfusion during systemic hypocapnia.