Michael S. Jastremski

Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care.

ObjectivesTo describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level. ParticipantsA multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM). Data Sources and SynthesisRelevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts. Consensus for the final written document was reached through collaboration in meetings and through electronic communication modalities. Literature cited included previously written guidelines from the ACCM, published expert opinion and statements from official organizations, published review articles, and nonrandomized, historical cohort investigations. With this background, the ACCM writing panel described a three-tiered system of intensive care units determined by service-based criteria. ConclusionsGuidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.

Effect of ibuprofen in patients with severe sepsis : a randomized, double-blind, multicenter study

ObjectiveTo evaluate the safety and physiologic actions of ibuprofen in patients with severe sepsis. DesignRandomized, double-blind, placebo-controlled trial. SettingThree university hospital medical ICUs. PatientsTwenty-nine patients with clinical evidence of sepsis and the need for hemodynamic monitoring with a pulmonary artery flotation catheter. InterventionsThirteen patients received placebo and 16 received ibuprofen that consisted of 600 mg (n = 11) or 800 mg (n = 5) iv over 20 mins, followed by three 800-mg doses administered as a rectal solution every 6 hrs. The initial iv dose was given within 4 hrs of the presumptive diagnosis of sepsis. Measurements and Main ResultsThe peak circulating total ibuprofen concentration after the iv dose (49.4 ± 4.5 μg/mL, mean ± SEM) was higher than peak concentrations after the three rectal doses (17.0 ± 2.7, 16.4 ± 3.0, 16.0 ± 3.1 μg/ mL). Both routes of ibuprofen administration were well tolerated. Frequent monitoring for gastrointestinal bleeding and assessment of renal and hepatic function failed to demonstrate significant differences between ibuprofen and placebo. Because a trend for reduced creatinine clearance was observed at 8 hrs in the ibuprofen group, nephrotoxicity of this drug in sepsis cannot be excluded.Temperature decreased significantly within 4 hrs of the initial dose of investigational therapy in patients who received ibuprofen (38.5 ± 0.3° to 37.0 ± 0.2°C, p < .001). However, despite this significant change in temperature, we were unable to detect significant differences in hemodynamic and respiratory values or survival when ibuprofen-treated patients were compared with controls. ConclusionsIbuprofen was well tolerated when administered iv and rectally to patients with severe sepsis, although drug absorption was poor with the rectal route. Significant antipyretic effects of ibuprofen were demonstrated. Although an excellent safety profile characterized ibuprofen in this study, the absence of ibuprofen-associated toxicity may have been secondary to poor rectal absorption of the drug. Our results support the continued clinical investigation of ibuprofen in sepsis, using an all-intravenous route of administration.

Regionalization of critical care medicine: task force report of the American College of Critical Care Medicine.

To review the existing literature and task force opinions on regionalization of critical care services, and to synthesize a judgment on possible costs, benefits, disadvantages, and strategies. Data Sources:Pertinent literature in the English language. Study Selection:One hundred forty-six English language papers were studied to determine possible ramifications of regionalization of critical care or other similar services. Data Extraction:Information on possible influence on the care of the critically ill was sought and integrated with the opinions of task force members. Possible costs, benefits, as well as disadvantages to the patient, transferring and receiving institutions, and region as a whole were sought. Data Synthesis:Regionalization of critical care services was thought to be advantageous to the patient. The larger academic institutions tend to have more resources, better subspecialty availability, and expertise in the care of the critically ill. Efficiency and safety during transport need to be in place. Disadvantages of overutilization, possible costliness to both the referring institution as well as to the receiving institution were outlined. It was agreed that pediatric critical care medicine was a separate issue. Conclusions:Regionalization of critical care medicine probably is beneficial and the concept should be explored. (Crit Care Med 1994; 22:1306–1313)

In-hospital cardiac arrest.

Patients who suffer an in-hospital cardiac arrest represent a neglected and underutilized resource for resuscitation research. There exists an unwritten, but widely held, belief among resuscitation researchers that the in-hospital arrest population is unsuitable for resuscitation research because it is composed mostly of patients whose cardiac arrest is the terminal event of a fatal illness. Despite the large numbers of hospitalized patients on whom cardiac resuscitation is attempted each year, there are few reports and even less true research devoted to this clinical problem. This article, which is intended to be provocative, reviews and summarizes the existing literature on in-hospital resuscitation from cardiac arrest, considers the advantages of resuscitation research in this setting, and concludes with a challenge to resuscitation researchers.

A model for technology assessment as applied to closed loop infusion systems

OBJECTIVESnTo test a model for the assessment of critical care technology on closed loop infusion control, a technology that is in its early stages of development and testing on human subjects.nnnDATA SOURCESnA computer-assisted search of the English language literature and reviews of the gathered data by experts in the field of closed loop infusion control systems.nnnSTUDY SELECTIONnStudies relating to closed loop infusion control that addressed one or more of the questions contained in our technology assessment template were analyzed. Study design was not a factor in article selection. However, the lack of well-designed clinical outcome studies was an important factor in determining our conclusions.nnnDATA EXTRACTIONnA focus person summarized the data from the selected studies that related to each of the assessment questions. The preliminary data summary developed by the focus person was further analyzed and refined by the task force. Experts in closed loop systems were then added to the group to review the summary provided by the task force. These experts comments were considered by the task force and this final consensus report was developed.nnnDATA SYNTHESISnClosed loop system control is a technological concept that may be applicable to several aspects of critical care practice. This is a technology in the early stages of evolution and much more research and data are needed before its introduction into usual clinical practice. Furthermore, each specific application and each device for each application (e.g., nitroprusside infusion, ventilator adjustment), although based on the same technological concept, are sufficiently different in terms of hardware and computer algorithms to require independent validation studies.nnnCONCLUSIONSnClosed loop infusion systems may have a role in critical care practice. However, for most applications, further development is required to move this technology from the innovation phase to the point where it can be evaluated so that its role in critical car practice can be defined. Each application of closed loop infusion systems must be independently validated by appropriately designed research studies. Users should be provided with the clinical parameters driving each closed loop system so that they can ensure that it agrees with their opinion of acceptable medical practice. Clinical researchers and leaders in industry should collaborate to perform the scientifically valid, outcome-based research that is necessary to evaluate the effect of this new technology. The original model we developed for technology assessment required the addition of several more questions to produce a complete analysis of an emerging technology. An emerging technology should be systematically assessed (using a model such as the model developed by the Society of Critical Care Medicine), before its introduction into clinical practice in order to provide a focus for human outcome validation trials and to minimize the possibility of widespread use of an unproven technology.

Analysis of the effects of continuous on-line monitoring of mixed venous oxygen saturation on patient outcome and cost-effectiveness

Continuous measurement of mixed venous oxygen saturation (Sv-O2) has recently been introduced as a monitoring and management technique in critical care patients. To determine the impact of Sv-O2 monitoring on patient management and cost-effectiveness, we conducted a prospective, randomized clinical trial of 99 consecutive patients receiving pulmonary artery (PA) catheters in the ICU. One group (n = 49) received an Edwards quadruple-lumen flow-directed PA catheter. Another group (n = 50) received the Oximetrix Opticath, a flow-directed PA catheter utilizing reflective fiberoptic oximetry for continuous Sv-O2 monitoring. Data recorded included APACHE and TISS scores, duration of stay, number of catheter days, incidence of catheter problems and changes, number of blood gases (arterial and venous), and ICU mortality. Additionally, the early warning capability of Sv-O2 monitoring was analyzed by comparing the severity and outcome of potentially adverse hemodynamic events in both groups. Statistical analysis by step-deletion multiple regression analysis and the unpaired Students t-test demonstrated that use of the Opticath was not associated with a decrease in potentially adverse hemodynamic events, length of ICU stay, or mortality. In terms of cost-effectiveness, mixed venous oximetry is economically favorable in a charge-based reimbursement system, but economically unfavorable in a fixed-cost-based reimbursement system. Although continuous Sv-O2 monitoring has been shown to be accurate and reliable, it does not appear to be beneficial in all patients requiring PA catheterization.

Relieving Overcrowded Emergency Departments through Ambulance Diversion

One citys solution to overcrowded emergency departments and a shortage of beds was the installation of an ambulance-diversion system, whereby ambulances carrying patients with relatively minor injuries were diverted, when necessary, from the citys busy emergency departments to less crowded ones in neighboring counties.

Predictors of electromechanical dissociation during cardiac arrest

ECG patterns observed during cardiac arrest were analyzed in 261 comatose cardiac arrest survivors. Forty-seven patients (18%) exhibited electromechanical dissociation (EMD) at some point before restoration of stable spontaneous circulation. These patients had a higher mortality (P = .05) and a lower rate of cerebral recovery (P = .01) during the one-year follow-up than study patients who did not exhibit EMD. Patients who developed EMD subsequent to defibrillation had better outcome than patients presenting with EMD. Multivariate analysis revealed that age more than 70 years old (P = .007), pulmonary disease (P less than .001), diabetes (P = .013, in-hospital arrests only), and prearrest hypoxemia (P = .013, outside-hospital arrests only) were independently predictive of the occurrence of EMD. Although the generalizability of these findings is limited, they may offer new clues to the pathophysiology of EMD.

High-frequency jet ventilation versus conventional ventilation after surfactant displacement in dogs.

High-frequency jet ventilation (HFJV) was compared with conventional ventilation (CV) after surfactant displacement with diocytyl sodium sulfosuccinate (OT) via ultrasonic nebulization. After aerosol delivery, dogs were separated into 3 groups and followed for 2 h. Ventilator settings were not changed in group I (CV) and group II (HFJV) after OT delivery. In group III, drive pressure was increased to 40 psi. Adequacy of oxygenation varied directly with peak inspiratory pressure (PIP) rather than airway pressure (Paw) in both HFJV and CV. In all groups, immediately after OT administration PaO2 decreased and there was a slight increase in Paw; PIP was significantly elevated only in groups I and HI. Two hours later, PaO2 had returned to baseline in groups I and III, but had not improved significantly in group II. Paw remained the same in all groups. These data demonstrate that in noncompliant lungs, oxygenation is not improved unless a high PIP is used to establish the critical opening pressures needed to rerecruit alveoli. In this noncompliant lung model, HFJV was not effective at low Paw values, and thus offered no apparent advantage over CV.

Prepubescent Gonococcal Vulvovaginitis: A Call for Examination of All Household Members

Investigation of a five-year-old girl with gonor rheal vulvovaginitis revealed four other cases in the household. This illustrates the importance of investigation of all family members in such cases.