Lewis A. Eisen

Ultrasound-guided catheterization of the radial artery: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND Ultrasound guidance commonly is used for the placement of central venous catheters (CVCs). The Agency for Healthcare Research and Quality recommends the use of ultrasound for CVC placement as one of its 11 practices to improve patient care. Despite increased access to portable ultrasound machines and comfort with ultrasound-guided CVC access, fewer clinicians are familiar with ultrasound-guided techniques of arterial catheterization. The goal of this systematic review and meta-analysis was to determine the utility of real-time two-dimensional ultrasound guidance for radial artery catheterization. METHODS A comprehensive literature search of Medline, Excerpta Medica Database, and the Cochrane Central Register of Controlled Trials by two independent reviewers identified prospective, randomized controlled trials comparing ultrasound guidance with traditional palpation techniques of radial artery catheterization. Data were extracted on study design, study size, operator and patient characteristics, and the rate of first-attempt success. A meta-analysis was constructed to analyze the data. RESULTS Four trials with a total of 311 subjects were included in the review, with 152 subjects included in the palpation group and 159 in the ultrasound-guided group. Compared with the palpation method, ultrasound guidance for arterial catheterization was associated with a 71% improvement in the likelihood of first-attempt success (relative risk, 1.71; 95% CI, 1.25-2.32). CONCLUSIONS The use of real-time two-dimensional ultrasound guidance for radial artery catheterization improved first-pass success rate.

Eye care in the intensive care unit: narrative review and meta-analysis.

Background:Patients in the intensive care unit are at increased risk of exposure keratopathy. Untreated, this may progress to microbial keratitis and visual loss. Data Synthesis:A total of 20% to 42% of patients in the intensive care unit develop exposure keratopathy. The epidemiology of this underappreciated problem is reviewed. The pathophysiology of microbial keratitis is reviewed with special attention to the multiple risk factors unique to intensive care unit patients. The clinical presentation of exposure keratopathy is reviewed with tips for recognition for the practicing clinician, including suggestions for when ophthalmologic consultation is warranted. Studies and case series of screening and prevention are reviewed in detail. Two of the most studied methods of prevention, moisture chambers and lubricating ointments, are formally compared in a meta-analysis. Eight of 113 (7.1%) patients in the moisture chamber group vs. 32 of 151 (21.2%) patients in the lubrication group developed exposure keratopathy, with a summary odds ratio of 0.208 (95% confidence interval 0.090–0.479, p < 0.001). Conclusion:With application of simple protocols, exposure keratopathy can be prevented, thus improving patient care in the intensive care unit.

A Program to Improve the Quality of Emergency Endotracheal Intubation

Objective: To assess the results of a quality improvement (QI) project designed to improve safety of emergency endotracheal intubation (EEI). Design: Single center prospective observational. Setting: 16-bed intensive care unit. Participants: Nine pulmonary/critical care fellows. Interventions: For 3 years, EEI performed by the medical intensive care unit team were analyzed to identify interventions that would improve quality of the procedure. By segmental process analysis, the procedure of EEI was subjected to iterative change. Major components of process improvement were development of a combined team approach, a mandatory checklist, use of crew resource management (CRM) tactics, and postevent debriefing. Quality analysis and improvement included training of fellows using scenario-based training (SBT) with computerized patient simulator (CPS) to improve mechanical skills of intubation and team leadership. Fellows received 15 sessions of SBT with CPS using a combined checklist and team approach before assuming team leadership position during real-life EEI. Measurements: For a 10-month period, fellows carried digital voice recorders to EEI; which, when combined with recording of continuous oximetry and BP monitoring were used to assess the quality of EEI. Main Results: 128 EEI were performed of which 101 had full data recorded. Complications were 14% severe hypoxemia (<80% saturation), 6% severe hypotension (SBP<70 mm Hg), 1% death, 20% difficult EEI (≥3 attempts), 11% esophageal intubations, 2% aspiration, and 1% dental injury; 62% EEI were successfully achieved on first attempt, 11% required >3 attempts. Conclusions: EEI may be performed by pulmonary/critical medicine (PCCM) fellows with safety comparable to that described in other studies on EEI. Important parts of the program included the use of formal iterative QI approach, the use of intensive SBT with CPS, basic CRM, a comprehensive checklist, and a combined team approach. A key benefit of the program was to make the process of EEI fully transparent for ongoing quality and safety improvement.

Non-invasive methods of estimating intracranial pressure.

Non-invasive measurement of intracranial pressure can be invaluable in the management of critically ill patients. We performed a comprehensive review of the literature to evaluate the different methods of measuring intracranial pressure. Several methods have been employed to estimate intracranial pressure, including computed tomography, magnetic resonance imaging, transcranial Doppler sonography, near-infrared spectroscopy, and visual-evoked potentials. In addition, multiple techniques of measuring the optic nerve and the optic nerve sheath diameter have been studied. Ultrasound measurements of the optic nerve sheath diameter and Doppler flow are especially promising and may be useful in selected settings.

What Went Right: Lessons for the Intensivist From the Crew of US Airways Flight 1549

On January 15, 2009, US Airways Flight 1549 hit geese shortly after takeoff from LaGuardia Airport in New York City. Both engines lost power, and the crew quickly decided that the best action was an emergency landing in the Hudson River. Due to the crews excellent performance, all 155 people aboard the flight survived. Intensivists can learn valuable lessons from the processes and outcome of this incident, including the importance of simulation training and checklists. By learning from the aviation industry, the intensivist can apply principles of crew resource management to reduce errors and improve patient safety. Additionally, by studying the impact of the mandated process-engineering applications within commercial aviation, intensivists and health-care systems can learn certain principles that, if adequately and thoughtfully applied, may seriously improve the art and science of health-care delivery at the bedside.

Barriers to ultrasound training in critical care medicine fellowships: A survey of program directors

Objective:Ultrasonography is an effective tool for making quick diagnoses and guiding therapeutic procedures. National organizations have advocated increasing the use of critical care ultrasonography. The purpose of this study was to investigate the prevalence of teaching of critical care ultrasonography in fellowship programs. In addition, we hoped to identify barriers to establishment of ultrasound training programs. Design:All pulmonary/critical care and critical care medicine (CCM) program directors in the United States were invited to participate in an online survey. We asked respondents for demographic information about their programs and perceived barriers to training, as well as current training opportunities for their fellows in five aspects of critical care ultrasonography. A five-point Likert scale was used for survey answers. Setting:Web-based survey. Subjects:Pulmonary/critical care and CCM program directors in the United States. Interventions:Web-based survey. Measurements and Main Results:Ninety (66%) of 136 program directors responded. Ultrasonography training was offered by fellowship programs in the following areas: vascular access (98%), lung and pleural (74%), cardiac (55%), vascular diagnostic (33%), and abdominal (37%). Ninety-two percent of respondents agreed or strongly agreed that ultrasound training is useful, and 80% were interested in getting their fellows trained. Forty-one percent indicated that they lacked sufficient faculty trained in ultrasound use. Eighty-four percent agreed or strongly agreed that fellow turnover was an impediment to training. Forty-eight percent believed that cardiac echocardiography required a long training time. Conclusions:Although ultrasound training in vascular access was nearly universal, training in other aspects of ultrasound was less prevalent. We identified several barriers, including fellow turnover, insufficient faculty training, and perceived length of time required for echocardiography training.

Confirmation of Endotracheal Tube Position: A Narrative Review

Endotracheal tube (ETT) insertion is the primary method of definitive airway protection and control in critically ill patients. Detection of ETT malposition in a timely fashion is crucial in both elective and emergent intubation. In this review, we describe classic tests and highlight several new technologies that may assist the practitioner in determining ETT position within the esophago-tracheal complex, namely ultrasonographic and impedance-based methods. Strengths and weaknesses of particular methods are highlighted. Although many physical examination maneuvers have been described, reliance on the physical examination alone is insufficient for confirmation. Touted methods that appear failsafe, such as direct visualization of the ETT traversing the vocal cords have limitations, especially when dealing in the emergency setting accompanying a difficult to visualize airway. While carbon dioxide detection is an excellent confirmatory method, it is not infallible. Esophageal detection devices are useful as an alternative means of confirmation. New methods such as ultrasonic location of the ETT show promise but require further study. The clinician performing ETT insertion should have multiple confirmation methods that allow the practitioner to adapt to a variety of clinical situations, depending on local costs and availability. Finally, when the clinician still has uncertainty, or multiple tests give conflicting results, the availability of bronchoscopy at the bedside to visualize the carina through the ETT is useful.

Competency in chest radiography. A comparison of medical students, residents, and fellows.

AbstractBACKGROUND: Accurate interpretation of chest radiographs (CXR) is essential as clinical decisions depend on readings. OBJECTIVE: We sought to evaluate CXR interpretation ability at different levels of training and to determine factors associated with successful interpretation. DESIGN: Ten CXR were selected from the teaching file of the internal medicine (IM) department. Participants were asked to record the most important diagnosis, their certainty in that diagnosis, interest in a pulmonary career and adequacy of CXR training. Two investigators independently scored each CXR on a scale of 0 to 2. PARTICIPANTS: Participants (n=145) from a single teaching hospital were third year medical students (MS) (n=25), IM interns (n=44), IM residents (n=45), fellows from the divisions of cardiology and pulmonary/critical care (n=16), and radiology residents (n=15). RESULTS: The median overall score was 11 of 20. An increased level of training was associated with overall score (MS 8, intern 10, IM resident 13, fellow 15, radiology resident 18, P<.001). Overall certainty was significantly correlated with overall score (r=.613, P<.001). Internal medicine interns and residents interested in a pulmonary career scored 14 of 20 while those not interested scored 11 (P=.027). Pneumothorax, misplaced central line, and pneumoperitoneum were diagnosed correctly 9%, 26%, and 46% of the time, respectively. Only 20 of 131 (15%) participants felt their CXR training sufficient. CONCLUSION: We identified factors associated with successful CXR interpretation, including level of training, field of training, interest in a pulmonary career and overall certainty. Although interpretation improved with training, important diagnoses were missed.

A Prerotational, Simulation-Based Workshop Improves the Safety of Central Venous Catheter Insertion: Results of a Successful Internal Medicine House Staff Training Program

BACKGROUND The purpose of this study was to evaluate the effectiveness of a simulation-based workshop with ultrasonography instruction in reducing mechanical complications associated with central venous catheter (CVC) insertion. METHODS A single-center prospective cohort study was conducted in the medical ICU and respiratory step-down unit of an urban teaching hospital. Fifty-six medical house staff members were trained prior to their rotations over a 6-month period. The data on mechanical complication rates after the implementation of the workshop were compared with previous experience when no structured educational program existed. RESULTS There were 334 procedures in the preeducation period compared to 402 procedures in the posteducation period. The overall complication rate, including placement failure, in the preeducation and posteducation period was 32.9% and 22.9%, respectively (P < .01). Placement failure rate decreased from 22.8% to 16.2% (P = .02), and arterial punctures decreased from 4.2% to 1.5% (P = .03). Ultrasonography usage increased from 3.0% to 61.4% (P < .01). Multivariate analysis demonstrated that interns were more likely to cause overall mechanical complications compared with fellows and attending physicians in the preeducation period (P = .02); however, this trend was not observed in the posteducation period. Catheter site and ultrasonography usage significantly affected the overall complication rate in both periods, and ultrasound-guided femoral CVC was the safest procedure in the posteducation period. CONCLUSIONS Implementation of a prerotational workshop significantly improved the safety of CVC insertion, especially for CVCs placed by inexperienced operators. We suggest that simulation-based training with ultrasonography instruction should be conducted if house staff members are responsible for CVC placement.

Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training

OBJECTIVE To determine the impact of simulation-based maternal cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff. STUDY DESIGN Maternal-Fetal Medicine staff (n = 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life support pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring. RESULTS Postintervention scores reflected statistically significant improvement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P = .042) and cesarean delivery (240 vs 159 seconds, P = .017). CONCLUSION Prompt cardiopulmonary resuscitation initiation and pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for Maternal-Fetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event.