Michael E. Ivy

Intra-abdominal hypertension and abdominal compartment syndrome in burn patients.

BACKGROUND Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are known to occur in patients after major abdominal surgery. The incidence of IAH and ACS in the burn population is not known. METHODS We prospectively recorded the intra-abdominal pressures of major burn patients admitted to our burn center from February 1999 to September 1999. A bladder pressure greater than 25 mm Hg was diagnosed as IAH. ACS was diagnosed when pulmonary compliance decreased in association with persistent IAH and was treated with abdominal decompression. RESULTS Ten patients were placed on the protocol; of these, seven developed IAH. Five responded to conservative treatment. Two patients with 80% body surface area burns developed ACS and required decompression. CONCLUSIONS IAH occurs commonly in major burn patients, and ACS is seen regularly in patients with more than 70% body surface area burns. We recommend bladder pressure measurements after infusion of more than 0.25 L/kg during the acute resuscitation phase and for peak inspiratory pressures greater than 40 cm H2O. Whereas ACS warrants surgical decompression of the abdominal cavity, IAH usually responds to conservative therapy.

Abdominal Compartment Syndrome in Patients With Burns

Abdominal compartment syndrome (ACS) is a well-recognized perioperative complication that occurs in patients who undergo intra-abdominal operations and who require extensive fluid resuscitation. The classic presentation of this syndrome includes high peak airway pressures; oliguria, despite adequate filling pressures; and intra-abdominal pressures of more than 25 mm Hg. A decompressive laparotomy performed at the bedside can alleviate ACS. If left untreated, sustained intra-abdominal hypertension is often fatal. In the literature, ACS has been described in pediatric patients with burns but not in adult patients with burns. This article describes 3 adults who sustained burns of more than 70% of their body surface areas, who required more than 20 L of crystalloid resuscitation, and who developed ACS during their resuscitation after the burn injury. The mortality rate among these patients was 100%, which confirms the grave consequences of this syndrome. In our institution, intra-abdominal pressure is now routinely measured as part of the burn resuscitation process in an attempt to diagnose and treat this syndrome earlier and more efficaciously. It is recommended that the possibility of ACS be considered when diagnosing any patient with burns who develops high airway pressures, oliguria, or both.

Guidelines for critical care medicine training and continuing medical education.

ObjectiveCritical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care. ParticipantsA multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine. ScopePhysician education in critical care medicine in the United States should encompass all disciplines that provide care in the intensive care unit and all levels of training: from medical students through all levels of postgraduate training and continuing medical education for all providers of clinical critical care. The scope of this guideline includes physician education in the United States from residency through ongoing practice after subspecialization. Data Sources and SynthesisRelevant literature was accessed via a systematic Medline search as well as by requesting references from all panel members. Subsequently, the bibliographies of obtained literature were reviewed for additional references. In addition, a search of organization-based published material was conducted via the Internet. This included but was not limited to material published by the American College of Critical Care Medicine, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and other primary and specialty organizations. Collaboratively and iteratively, the task force met, by conference call and in person, to construct the tenets and ultimately the substance of this guideline. ConclusionsGuidelines for the continuum of education in critical care medicine from residency through specialty training and ongoing throughout practice will facilitate standardization of physician education in critical care medicine.

Dilatational percutaneous tracheostomy : Modification of technique

BACKGROUND Major inherent risks associated with percutaneous dilatational tracheostomy include loss of airway during endotracheal tube manipulation, inability to cannulate the trachea below the endotracheal tube, and difficulties related to neck anatomy. METHOD Percutaneous dilatational tracheostomy technique was modified to make the incision in the suprasternal area, and the use of air leak technique confirmed tracheal penetration below the endotracheal cuff. Bronchoscopy was not used. RESULTS One hundred patients underwent percutaneous dilatational tracheostomy using the modification mentioned above. Although three patients had minor bleeding complications, there was no loss of airway; nor were there other complications. CONCLUSION This technique provides improved safety from loss of airway and illuminates the need for concomitant bronchoscopy.

Critical care medicine education of surgeons : Recommendations from the Surgical Section of the Society of Critical Care Medicine

Perspective: The role of surgeons in critical care medicine has a long and esteemed past. The presence of surgeons in intensive care units provides specific insights and perspectives to the care of surgical patients sometimes not fully appreciated by the nonsurgical practitioners caring for the same patients. The training and education of surgeons is becoming more complex, fragmented, and lengthy. The knowledge base and skill set required to manage critically ill or injured surgical patients is also becoming more extensive but has the potential of becoming lost in the process of providing the overall educational program for surgical trainees. Simultaneously, nonsurgical specialties are continuing to train individuals with special skills in critical care medicine and the concept of “hospitalists” is becoming more accepted by institutions across the United States. The certification exams in critical care medicine remain under the aegis of the individual medical specialty boards, and there is still not a unified examination process in critical care. Surgeons, in particular, have tremendous pressures these days to spend more clinical time in the operating room, and the task of consistently conducting high quality research is also becoming arduous. This list of reasons could continue but are simply examples for why surgeons need to spend focused attention on how best to train and educate upcoming surgical trainees in regards to the principles of critical care medicine. The critically ill or injured patients need this focused attention and the specialty of surgical critical care medicine needs this attention. The Surgical Section of the Society of Critical Care Medicine has developed this position statement in the hopes that ongoing discussion and refinement of this particular aspect of surgery will continue on several levels.

Acute Care Surgery Survey: Opinions of Surgeons About a New Training Paradigm

HYPOTHESIS The acute care surgery (ACS) 2-year training model, incorporating surgical critical care (SCC), trauma surgery, and emergency general surgery, was developed to improve resident interest in the field. We believed that analysis of survey responses about the new training paradigm before its implementation would yield valuable information on current practice patterns and on opinions about the ACS model. DESIGN Two surveys. PARTICIPANTS Members of the Surgery Section of the Society of Critical Care Medicine and SCC program directors. INTERVENTIONS One survey was sent to SCC program directors to define the practice patterns of trauma and SCC surgeons at their institutions, and another survey was sent to all Surgery Section of the Society of Critical Care Medicine members to solicit opinions about the ACS model. MAIN OUTCOME MEASURES Practice patterns of trauma and SCC surgeons and opinions about the ACS model. RESULTS Fifty-seven of 87 SCC program directors responded. Almost all programs are associated with level I trauma centers with as many as 15 trauma surgeons. Most of these trauma surgeons cover SCC and emergency general surgery. Sixty-six percent of surgical intensive care units are semiclosed; 89.0% have surgeons as directors. Seventy percent of the staff in surgical intensive care units are surgeons. One hundred fifty-five of approximately 1100 Surgery Section of the Society of Critical Care Medicine members who responded to the other survey did not believe that the ACS model would compromise surgical intensive care unit and trauma care or trainee education yet would allow surgeons to maintain their surgical skills. Respondents were less likely to believe that the ACS fellowship would be important financially, increase resident interest, or improve patient care. CONCLUSIONS In academic medical centers, surgical intensivists already practice the ACS model but depend on many nonsurgeons. Surgical intensivists believe that ACS will not compromise care or education and will help maintain the field, although the effect on resident interest is unclear.

Characterizing the practice of surgical critical care fellowship graduates: What's a fellow to do?

Abstract In order to characterize further the developing field of surgical critical care, we mailed letters to surgical critical care fellowship directors requesting the addresses of their graduates. We then mailed out surveys to the graduates and analyzed their responses. Resident teaching is a prominent feature for 85% of the graduates, with 94% of them teaching surgical critical care and 84% teaching general surgery residents. Sixty-five percent of the respondents spend at least 25% of their time providing surgical critical care, and 56% actively practice some aspects of general surgery as well. Not surprisingly, trauma care is a large part of the surgical intensivists practice, with 74% also spending at least 25% of their clinical time caring for trauma patients. With this mix of responsibilities, the respondents performed an average of 148 operations annually. Of the surgeons who responded to the survey, 66% have academic practices. Over 75% were salaried, with 95% earning over

Critical care education of surgical residents: a survey of general surgery residency programs

100,000 annually and 40% earning in excess of

Commentary: Disruptive Physicians

150,000. Practice arrangements and patient mix varied substantially within the field. Several issues regarding the career choice of surgical critical care have been raised in previous studies, and the current survey helps to clarify several of these issues. Further surveys and follow-up studies are urgently needed to better characterize the career profile for surgical critical care.

Traumatic and iatrogenic Horner syndrome: case reports and review of the literature.

Abstract Critical care education may vary in general surgery residency programs because no specific guidelines for this type of training exist. In order to determine the current state of resident education in the ICU, a survey was sent to all general surgery program directors. Of the 217 programs responding, 90% had a dedicated ICU rotation. Surgical residents at the PGY-1 (27%) or PGY-2 (46%) level had a 1- (37%) or 2- (49%) month rotation in the ICU. Teaching formats included: bedside rounds (94% of programs), formal lectures (75%), patient problem-based reading (37%), assigned texts (34%), computers (20%), and videotapes (17%) or audiotapes (10%). Procedures were taught mainly by the senior house staff or faculty. Although the curriculum included a broad spectrum of critical care topics, ventilator management and respiratory failure were the only topics universally covered. Resident education in the ICU varies among general surgery programs. The data from this study establish a baseline for following the educational process as more uniform recommendations are developed and the use of novel educational techniques becomes more common.