Michael L. Green

The Internal Medicine Reporting Milestones and the Next Accreditation System

The Accreditation Council for Graduate Medical Education (ACGME) developed the Milestones Project to facilitate more synthetic and narrative-based assessments of educational outcomes. This commenta...

Internal medicine milestones.

William Iobst, MD, is Vice President of Academic Affairs, American Board of Internal Medicine; Eve Aagaard, MD, is Associate Professor of Medicine, University of Colorado School of Medicine; Hasan Bazari, MD, is Program Director, Internal Medicine Residency Program, Massachusetts General Hospital, and Associate Professor of Medicine, Harvard Medical School; Timothy Brigham, MDiv, PhD, is Chief of Staff and Senior Vice President, Department of Education, Accreditation Council for Graduate Medical Education; Roger W. Bush, MD, is Attending Physician, Virginia Mason Medical Center; Kelly Caverzagie, MD, is Assistant Professor of Medicine and Associate Vice Chair for Quality and Physician Competence, Department of Internal Medicine, University of Nebraska Medical Center; Davoren Chick, MD, is Clinical Assistant Professor of Medicine, Department of Internal Medicine, University of Michigan Medical School; Michael Green, MD, is Professor of Medicine, Yale University School of Medicine; Kevin Hinchey, MD, is Associate Professor, Tufts University School of Medicine, and Chief Academic Officer, Baystate Medical Center; Eric Holmboe, MD, is Chief Medical Officer, American Board of Internal Medicine; Sarah Hood, MS, is Director of Academic Affairs, American Board of Internal Medicine; Gregory Kane, MD, is Professor of Medicine, Interim Chairman of the Department of Medicine, Jefferson Medical College; Lynne Kirk, MD, is Professor of Internal Medicine, University of Texas Southwestern Medical Center; Lauren Meade, MD, is Assistant Professor of Medicine, Tufts University School of Medicine, and Associate Program Director for Internal Medicine, Baystate Medical Center, and Chair of Educational Research Outcomes Collaborative–Internal Medicine; Cynthia Smith, MD, is Senior Medical Associate for Content Development, American College of Physicians, and Adjunct Associate Professor, Perelman School of Medicine; and Susan Swing, PhD, is Vice President, Outcome Assessment, Accreditation Council for Graduate Medical Education.

Electrical activity of the diaphragm during extubation readiness testing in critically ill children

Objectives: To investigate the electrical activity of the diaphragm during extubation readiness testing. Design: Prospective observational trial. Setting: A 29-bed medical-surgical pediatric intensive care unit. Patients: Mechanically ventilated children between 1 month and 18 yrs of age. Interventions: Twenty patients underwent a standardized extubation readiness test using a minimal pressure support ventilation strategy. A size-appropriate multiple-array esophageal electrode (electrical diaphragmatic activity catheter), which doubled as a feeding tube, was inserted. The electrical diaphragmatic activity, ventilatory parameters, and spirometry measurements were recorded with the Servo-i ventilator (Maquet, Solna, Sweden). Measurements were obtained before the extubation readiness test and 1 hr into the extubation readiness test. Measurements and Main Results: During extubation readiness testing, the ratio of tidal volume to delta electrical diaphragmatic activity was significantly lower in those patients who passed the extubation readiness test compared to those who failed the extubation readiness test (extubation readiness test, pass: 24.8 ± 20.9 mL/&mgr;V vs. extubation readiness test, fail: 67.2 ± 27 mL/&mgr;V, respectively; p = .02). Delta electrical diaphragmatic activity correlated significantly with neuromuscular drive assessed by airway opening pressure at 0.1 secs (before extubation readiness test: r = .591, p < .001; during extubation readiness test: r = .682, p < .001). Eight out of 20 patients had ventilator dys-synchrony identified with electrical diaphragmatic activity during extubation readiness testing. Conclusions: Patients who generate higher diaphragmatic activity in relation to tidal volume may have better preserved diaphragmatic function and a better chance of passing the extubation readiness test as opposed to patients who generate lower diaphragmatic activity in relation to tidal volume, indicating diaphragmatic weakness. Electrical activity of the diaphragm also may be a useful adjunct to assess neuromuscular drive in ventilated children.

Adrenocortical function in the postoperative pediatric cardiac surgical patient.

Purpose of review Corticosteroids are frequently used in the postoperative care of children with congenital heart disease. This review describes the function of the adrenocortical axis in this population and the effects of corticosteroids on cardiovascular function. In addition, it examines the diagnosis of adrenal insufficiency in this population and provides an overview of recent studies on the use of steroids in treating hemodynamic instability in these children. Recent findings Corticosteroids improve hemodynamic parameters in children with shock following congenital heart surgery. This improvement may be due to treatment of adrenal insufficiency or from direct cardiovascular effects of corticosteroids. The diagnosis of adrenal insufficiency in this population is challenging as low cortisol levels do not consistently correlate with adverse outcomes. Summary Because of the lack of evidence delineating what the normal adrenocortical function is in this population, cortisol levels alone are not sufficient to justify treating with steroids in this population. Corticosteroids are beneficial in improving hemodynamics in children with shock after congenital heart surgery, but the adverse effects of the therapy in this context are not fully known. Prospective trials are necessary to clarify which patients may benefit from steroid therapy and to examine long-term effects of steroids.

Underweight Status Is an Independent Predictor of In-Hospital Mortality in Pediatric Patients on Extracorporeal Membrane Oxygenation.

BACKGROUND Malnutrition is associated with an increased risk of mortality in patients admitted to the intensive care unit. Children requiring extracorporeal membrane oxygenation (ECMO) support represent an extremely ill subset of this population. There is a lack of data on the impact of nutrition state on survival in this cohort. We examined the association between being underweight and in-hospital mortality among children supported with ECMO. MATERIALS AND METHODS This article reports on an observational retrospective cohort study performed among neonatal and pediatric patients supported with ECMO in a tertiary childrens hospital from May 1996 through June 2013. Nutrition status on intensive care unit admission was defined with z scores on weight for length and body mass index. RESULTS Patients (N = 491) had a median age of 31 days (interquartile range, 2-771): 24.4% were underweight, and 8.9% were obese. During ECMO support, 88.3% received total parenteral nutrition, and 30.3% received enteral nutrition. Median maximum energy intake while receiving ECMO was 82 kcal/kg/d (interquartile range, 54.7-105). Multiple logistic regression showed that underweight status was associated with increased predicted odds of in-hospital mortality when compared with normal weight (odds ratio: 1.99, 95% confidence interval: 1.21-3.25, P = .006). Other factors associated with increased odds of mortality included extracorporeal cardiopulmonary resuscitation and the need for continuous renal replacement therapy. CONCLUSION Underweight status was an independent predictor for in-hospital mortality in our cohort of pediatric ECMO patients. Prospective studies evaluating the impact of metabolic state of children on ECMO should further define this relationship.

Electrocardiographic Guidance for the Placement of Gastric Feeding Tubes: A Pediatric Case Series

BACKGROUND: The placement of nasal or oral gastric tubes is one of the most frequently performed procedures in critically ill children; tube malposition, particularly in the trachea, is an important complication. Neurally adjusted ventilatory assist (NAVA) ventilation (available only on the Servo-i ventilator, Maquet Critical Care, Solna, Sweden) requires a proprietary-design catheter (Maquet Critical Care, Solna, Sweden) with embedded electrodes that detect the electrical activity of the diaphragm (EAdi). The EAdi catheter has the potential benefit of confirming proper positioning of a gastric catheter, based on and the EAdi waveforms. METHODS: In a case series study, our multidisciplinary team used EAdi guidance for immediate, real-time confirmation of proper nasal or oral gastric tube placement in 20 mechanically ventilated pediatric patients who underwent 23 oral or nasal gastric tube placements. The catheters were placed with our standard practice, with the addition of a team member monitoring the EAdi waveforms. As the tube passes down the esophagus and posterior to the heart, a characteristic EAdi pattern is identified and the position of the atrial signal confirms correct placement of the gastric tube. If the EAdi waveforms indicate incorrect placement, the tube is repositioned until the proper EAdi waveform pattern is obtained. Then proper tube placement is reconfirmed via auscultation over the stomach while air is injected into the catheter, checking the pH of fluid suctioned from the catheter (gastric pH indicates correct positioning), and/or radiograph. RESULTS: The groups median age was 3 years (range 4 d to 16 y). All 20 patients had successful gastric catheter placement. The EAdi catheter provided characteristic patterns for correctly placed tubes, tubes malpositioned above or below the gastroesophageal junction, and curled tubes. Proper catheter position was confirmed via radiograph and/or gastric pH in all 20 patients. CONCLUSIONS: EAdi guidance helps confirm proper gastric catheter position, is equivalent to our standard practice for confirming gastric catheter placement, and may reduce the need for radiographs and improve patient safety by avoiding catheter malpositions.

Developing a Tool to Assess Placement of Central Venous Catheters in Pediatrics Patients

BACKGROUND Pediatric critical care medicine requires the acquisition of procedural skills, but to date no criteria exist for assessing trainee competence in central venous catheter (CVC) insertion. OBJECTIVE The goal of this study was to create and demonstrate validity evidence for a direct observation tool for assessing CVC insertion. METHODS Ten experts used the modified Delphi technique to create a 15-item direct observation tool to assess 5 scripted and filmed simulated scenarios of CVC placement. The scenarios were hosted on a dedicated website from March to May 2013, and respondents recruited by e-mail completed the observation tool in real time while watching the scenarios. The goal was to obtain 50 respondents and a total of 250 scenario ratings. RESULTS A total of 49 pediatrics intensive care faculty physicians (6.3% of 780 potential subjects) responded and generated 188 scenario observations. Of these, 150 (79.8%) were recorded from participants who scored 4 or more on the 5 scenarios. The tool correctly identified the expected reference standard in 96.8% of assessments with an interrater agreement kappa (standard error) = 0.94 (0.07) and receiver operating characteristic = 0.97 (95% CI 0.94-0.99). CONCLUSIONS This direct observation assessment tool for central venous catheterization demonstrates excellent performance in identifying the reference standard with a high degree of interrater reliability. These assessments support a validity construct for a pediatric critical care medicine faculty member to assess a provider placing a CVC in a pediatrics patient.

Defining leadership competencies for pediatric critical care fellows: Results of a national needs assessment

Abstract Introduction: Physicians in training, including those in Pediatric Critical Care Medicine, must develop clinical leadership skills in preparation to lead multidisciplinary teams during their careers. This study seeks to identify multidisciplinary perceptions of leadership skills important for Pediatric Critical Care Medicine fellows to attain prior to fellowship completion. Methods: We performed a multi-institutional survey of Pediatric Critical Care Medicine attendings, fellows, and nurses. Subjects were asked to rate importance of 59 leadership skills, behaviors, and attitudes for Pediatric Critical Care practitioners and to identify whether these skills should be achieved before completing fellowship. Skills with the highest ratings by respondents were deemed essential. Results: Five hundred and eighteen subjects completed the survey. Of 59 items, only one item (“displays honesty and integrity”) was considered essential by all respondents. When analyzed by discipline, nurses identified 21 behaviors essential, fellows 3, and attendings 1 (p < 0.05). Nurses differed (p < 0.05) from attendings in their opinion of importance in 64% (38/59) of skills. Conclusions: Despite significant variability among Pediatric Critical Care attendings, fellows, and nurses in identifying which clinical leadership competencies are important for graduating Pediatric Critical Care fellows, they place the highest importance on skills in self-management and self-awareness. Leadership skills identified as most important may guide the development of interventions to improve trainee education and interprofessional care.

The Prone Position in Acute Lung Injury

Refractory hypoxemia is a characteristic feature of severe ARDS. Over the last 30 years, prone positioning is one intervention clinicians have used to improve oxygenation in these patients. Prone positioning improves oxygenation via better ventilation-to-perfusion matching and improved lung mechanics while reducing the potential for ventilator-associated lung injury. In both pediatric and adult studies, prone positioning has been found to be a safe and relatively noninvasive maneuver for patients with ARDS. Though prone positioning clearly improves oxygenation, clinical trials have not demonstrated improvements in survival or morbidity.

Inhaled anesthetic for life-threatening bronchospasm: is it ready for prime time?

Despite trends toward lower overall hospitalization rates for pediatric asthma, children requiring admission have an increasing frequency of admission to the ICU.[1][1],[2][2] Of these children, 6–26% develop respiratory failure requiring mechanical ventilation.[3][3]–[5][4] Though intubation