Nancy W. Knudsen

Sedation in the intensive care unit.

Objective: To describe the goals of sedative use in the intensive care unit and review the pharmacology of commonly used sedative drugs as well as to review pertinent publications in the literature concerning the comparative pharmacology of these drugs, with emphasis on outcomes related to sedation and comparative pharmacoeconomics. Data Sources: Publications in the scientific literature. Data Extraction: Computer search of the literature with selection of representative articles. Synthesis: Proper choice and use of sedative drugs is based on knowledge of the pharmacology of commonly used agents and is an essential component of caring for patients in the intensive care unit. The large variability in pharmacokinetics and pharmacodynamics in the critically ill make it difficult to directly compare agents. Midazolam provides rapid and reliable amnesia, even when administered for low levels of sedation. Propofol may be useful when deeper levels of sedation and more rapid awakening are required. Lorazepam can be used for long‐term sedation in more stable patients if rapidity of effect is not required. Further investigation in assessment of depth of sedation in the critically ill is needed. Continued study of costs, side effects, and appropriate dosing strategies of all sedative agents is needed to answer questions not sufficiently addressed in the current literature. Conclusion: An individualized approach to sedation based on knowledge of drug pharmacology is needed because of confounding variables including concurrent patient illness, depth of sedation, and concomitant use of analgesic agents.

Massive Transfusion Exceeding 50 Units of Blood Products in Trauma Patients

BACKGROUND Massive transfusion of blood products in trauma patients can acutely deplete the blood bank. It was hypothesized that, despite a large allocation of resources to trauma patients receiving more than 50 units of blood products in the first 24 hours, outcome data would support the continued practice of massive transfusion. METHODS A retrospective review of charts and registry data of trauma patients who received over 50 units of blood products in the first day was conducted for a 5-year period at a Level I trauma center. Patients were stratified into groups on the basis of the number of transfusions received. Results are expressed as mean +/- SD. Univariate analysis and multivariate logistic regression were used to identify those risk factors determined in the first 24 hours after admission that were predictive of mortality. Physiologic differences between survivors and nonsurvivors were also examined. RESULTS Of 7,734 trauma patients admitted between July 1, 1995, and June 30, 2000, 44 (0.6%) received > 50 units of blood products in the first day. Overall mortality in these patients was 57%. There was no significant difference (p = 0.565, chi2) in mortality rate between patients who received > 75 units of blood products in the first day versus those who received 51 to 75 units. Multiple logistic regression analysis identified only one independent risk factor, base deficit > 12 mmol/L, associated with mortality. Base deficit > 12 mmol/L increases the risk of death by 5.5 times (p = 0.013; 95% confidence interval, 1.44-20.95). Neither the total blood product transfusion requirement in the first day nor the packed red blood cell transfusion amount in the first day were significant independent risk factors. Causes of the 25 deaths in this series included exsanguination in the operating room (n = 1) or in the surgical intensive care unit (n = 12), multiple organ failure/sepsis (n = 3), head injury (n = 3), respiratory failure (n = 2), cerebrovascular accident (n = 1), and other (n = 3). Of the survivors, 63% were discharged to home, 21% to rehabilitation, 11% to nursing home, and 5% to another acute care facility. Of the nonsurvivors, the mean Injury Severity Score was 43, 88% had a base deficit > 12 mmol/L, 68% had a Glasgow Coma Scale score < 8, and 64% had a Sequential Organ Failure Assessment score > 10. CONCLUSION The 43% survival rate in trauma patients receiving > 50 units of blood products warrants continued aggressive transfusion therapy in the first 24 hours after admission.

Current teaching and evaluation methods in critical care medicine : Has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit?

Objective:To determine the impact of the Accreditation Council for Graduate Medical Education mandates for duty hours and competencies on instruction, evaluation, and patient care in intensive care units in the United States. Design:A Web-based survey was designed to determine the current methods of teaching and evaluation in the intensive care unit, barriers to changing methods of teaching and evaluation, and the impact of Accreditation Council for Graduate Medical Education regulations on teaching and patient care. Setting:An anonymous Web-based survey was used; cumulative data were analyzed. Subjects:A total of 125 of 380 program directors (33%) for pediatric critical care, pulmonary critical care, anesthesiology critical care, and surgery critical care fellowship programs completed questionnaires. Measurements and Main Results:Bedside case-based teaching and standardized lectures are the most common methods of education in the intensive care unit. Patient safety and resident demands are two factors most likely to result in changes in instruction in the intensive care unit. Barriers to changes in education include clinical workload and lack of protected time and funding. Younger respondents viewed influences to change differently than older respondents. Respondents felt that neither education nor patient care had improved as a result of the Accreditation Council for Graduate Medical Education mandates. Conclusions:Medical education teaching methods and assessment in the intensive care unit have changed little since the initiation of the Accreditation Council for Graduate Medical Education regulations despite respondents’ self-report of a willingness to change. Instead, the Accreditation Council for Graduate Medical Education regulations are thought to have negatively impacted resident attitudes, continuity of care, and even availability for teaching. These concerns, coupled with lack of protected time and funding, serve as barriers toward changes in critical care graduate medical education.

Regional anesthesia for thyroidectomy in two patients with amiodarone-induced hyperthyroidism.

A miodarone is a potent antiarrhythmic with a wide spectrum of activity in the treatment of both atria1 and ventricular arrythmias. Unfortunately, its antiarrhythmic efficacy is counterbalanced by a variety of serious side effects, including pneumonitis and thyroid disease (1). Because of its ability to liberate iodine, amiodarone can cause hyperthyroidism, which is often refractory to conventional treatment (2,3). These patients are frequently intolerant of p-blockade due to their underlying cardiomyopathies. Continuing life-threatening manifestations of thyroid excess with medical management has led to the performance of surgical thyroidectomy, which provides prompt, effective metabolic control (4). Little information is available regarding the anesthetic management of these patients. Anesthetic concerns include the medical condition for which amiodarone was originally given, associated side effects of the drug, uncontrolled hyperthyroid state, and any coexisting diseases (1,5). We report the use of regional anesthesia in two patients with amiodarone-induced hyperthyroidism having surgical thyroidectomy after failed medical management.

How Prepared Are Medical and Nursing Students to Identify Common Hazards in the Intensive Care Unit

Rationale: Care in the hospital is hazardous. Harm in the hospital may prolong hospitalization, increase suffering, result in death, and increase costs of care. Although the interprofessional team is critical to eliminating hazards that may result in adverse events to patients, professional students’ formal education may not prepare them adequately for this role. Objectives: To determine if medical and nursing students can identify hazards of hospitalization that could result in harm to patients and to detect differences between professions in the types of hazards identified. Methods: Mixed‐methods observational study of graduating nursing (n = 51) and medical (n = 93) students who completed two “Room of Horrors” simulations to identify patient safety hazards. Qualitative analysis was used to extract themes from students’ written hazard descriptions. Fishers exact test was used to determine differences in frequency of hazards identified between groups. Results: Identification of hazards by students was low: 66% did not identify missing personal protective equipment for a patient on contact isolation, and 58% did not identify a medication administration error (medication hanging for a patient with similar name). Interprofessional differences existed in how hazards were identified: medical students noted that restraints were not indicated (73 vs. 2%, P < 0.001), whereas nursing students noted that there was no order for the restraints (58.5 vs. 0%, P < 0.0001). Nursing students discovered more issues with malfunctioning or incorrectly used equipment than medical students. Teams performed better than individuals, especially for hazards in the second simulation that were similar to those in the first: need to replace a central line with erythema (73% teams identified) versus need to replace a peripheral intravenous line (10% individuals, P < 0.0001). Nevertheless, teams of students missed many intensive care unit‐specific hazards: 54% failed to identify the presence of pressure ulcers; 85% did not notice high tidal volumes on the ventilator; and 90% did not identify the absence of missing spontaneous awakening/breathing trials and absent stress ulcer prophylaxis. Conclusions: Graduating nursing and medical students missed several hazards of hospitalization, especially those related to the intensive care unit. Orientation for residents and new nurses should include education on hospitalization hazards. Ideally, this orientation should be interprofessional to allow appreciation for each others roles and responsibilities.

Cost Containment in Vascular Surgery

In the last decade, the delivery of health care and the role of the physician have undergone radical change. With the ad vent of managed care and the tightening of restrictions by Medicare and insurance companies, physicians have been required to review, re-engineer, and revitalize their role. Increasing financial pressures at the hospital level have caused administrators to cut costs at all levels. It is imper ative that physicians take an active role in cost containment so that the quality of care is not sacrificed. Cost containment in vascular surgery is an urgent priority in health care. Copyright