Nathan J. Smischney

Evaluation of preintubation shock index and modified shock index as predictors of postintubation hypotension and other short-term outcomes

PURPOSE Preintubation shock index (SI) and modified shock index (MSI) have demonstrated predictive capability for postintubation hypotension in emergency department. The primary aim was to explore this relationship in the critical care environment. The secondary aims were to evaluate the relationship of shock indices with other short-term outcomes like mortality and length of stay in intensive care unit. MATERIALS AND METHODS This is a nonconcurrent cohort study, conducted in eligible 140 adult intensive care unit (ICU) patients of a tertiary care medical center. Eligibility criterion was emergent endotracheal intubation in apparently hemodynamically stable patients. RESULTS Preintubation SI ≥ 0.90 had a significant association with postintubation hypotension as defined by systolic blood pressure < 90 mm Hg in the univariate (P = .03; odds ratio [OR], 2.13; 95% confidence interval [CI], 1.07-4.35) and multivariate analyses (P = .01; OR, 3.17; 95% CI, 1.36-7.73) after adjusting for confounders. It was also associated with higher ICU mortality in both the univariate (P = .01; OR, 4.00; 95% CI, 1.26-12.67) and multivariate analyses (P = .01; OR, 5.75; 95% CI, 1.58-26.48). There was no association of preintubation MSI with postintubation hemodynamic instability and ICU mortality. No association was found between preintubation SI and MSI, with ICU length of stay and 30-day mortality. CONCLUSIONS Our findings indicate that preintubation SI greater than or equal to 0.90 is a predictor of postintubation hypotension (systolic blood pressure <90 mm Hg) and ICU mortality in emergently intubated adult patients in intensive care units.

Incidence of and Risk Factors For Post-Intubation Hypotension in the Critically Ill

Background We aim to report the incidence of post-intubation hypotension in the critically ill, to report in-hospital mortality and length of stay in those who developed post-intubation hypotension, and to explore possible risk factors associated with post-intubation hypotension. Material/Methods Adult (≥18 years) ICU patients who received emergent endotracheal intubation were included. We excluded patients if they were hemodynamically unstable 60 minutes pre-intubation. Post-intubation hypotension was defined as the administration of any vasopressor within 60 minutes following intubation. Results Twenty-nine patients developed post-intubation hypotension (29/147, 20%). Post-intubation hypotension was associated with increased in-hospital mortality (11/29, 38% vs. 19/118, 16%) and length of stay (21 [10–37] vs. 12 [7–21] days) on multivariate analysis. Three risk factors for post-intubation hypotension were identified on multivariate analysis: 1) decreasing mean arterial pressure pre-intubation (per 5 mmHg decrease) (p-value=0.04; 95% CI 1.01–1.55); 2) administration of neuromuscular blockers (p-value=0.03; 95% CI 1.12–6.53); and 3) intubation complication (p-value=0.03; 95% CI 1.16–15.57). Conclusions Post-intubation hypotension was common in the ICU and was associated with increased in-hospital mortality and length of stay. These patients were more likely to have had lower mean arterial pressure prior to intubation, received neuromuscular blockers, or suffered a complication during intubation.

Ketamine and Propofol Combination (“Ketofol”) for Endotracheal Intubations in Critically Ill Patients: A Case Series

Case series Patient: Male, 77 • Male, 25 • Male, 63 • Male, 70 • Male, 70 • Female, 61 Final Diagnosis: — Symptoms: Hypotension • respiratory failure Medication: Ketamine • Propofol • Etomidate Clinical Procedure: Endotracheal intubation Specialty: Critical Care Medicine Objective: Educational Purpose (only if useful for a systematic review or synthesis) Background: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation. Case Series: We describe 6 cases in which the combination of ketamine and propofol (“ketofol”) was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations. Conclusions: This case series describes the use of the “ketofol” combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.

Retrospective derivation and validation of a search algorithm to identify emergent endotracheal intubations in the intensive care unit.

BACKGROUND The development and validation of automated electronic medical record (EMR) search strategies are important in identifying emergent endotracheal intubations in the intensive care unit (ICU). OBJECTIVE To develop and validate an automated search algorithm (strategy) for emergent endotracheal intubation in the critically ill patient. METHODS The EMR search algorithm was created through sequential steps with keywords applied to an institutional EMR database. The search strategy was derived retrospectively through a secondary analysis of a 450-patient subset from the 2,684 patients admitted to either a medical or surgical ICU from January 1, 2010, through December 31, 2011. This search algorithm was validated against an additional 450 randomly selected patients. Sensitivity, specificity, and negative and positive predictive values of the automated search algorithm were compared with a manual medical record review (the reference standard) for data extraction of emergent endotracheal intubations. RESULTS In the derivation subset, the automated electronic note search strategy achieved a sensitivity of 74% (95% CI, 69%-79%) and a specificity of 98% (95% CI, 92%-100%). With refinements in the search algorithm, sensitivity increased to 95% (95% CI, 91%-97%) and specificity decreased to 96% (95% CI, 92%-98%) in this subset. After validation of the algorithm through a separate patient subset, the final reported sensitivity and specificity were 95% (95% CI, 86%-99%) and 100% (95% CI, 98%-100%). CONCLUSIONS Use of electronic search algorithms allows for correct extraction of emergent endotracheal intubations in the ICU, with high degrees of sensitivity and specificity. Such search algorithms are a reliable alternative to manual chart review for identification of emergent endotracheal intubations.

Derivation and validation of a search algorithm to retrospectively identify mechanical ventilation initiation in the intensive care unit

BackgroundThe development and validation of automated electronic medical record (EMR) search strategies are important for establishing the timing of mechanical ventilation initiation in the intensive care unit (ICU).Thus, we sought to develop and validate an automated EMR search algorithm (strategy) for time zero, the moment of mechanical ventilation initiation in the critically ill patient.MethodsThe EMR search algorithm was developed on the basis of several mechanical ventilation parameters, with the final parameter being positive end-expiratory pressure (PEEP), and was applied to a comprehensive institutional EMR database. The search algorithm was derived from a secondary retrospective analysis of a subset of 450 patients from a cohort of 2,684 patients admitted to a medical ICU and a surgical ICU from January 1, 2010, through December 31, 2011. It was then validated in an independent subset of 450 patients from the same period. The overall percent of agreement between our search algorithm and a comprehensive manual medical record review in the derivation and validation subsets, using peak inspiratory pressure (PIP) as the reference standard, was compared to assess timing of mechanical ventilation initiation.ResultsIn the derivation subset, the automated electronic search strategy achieved an 87% (κ = 0.87) perfect agreement, with 94% agreement to within one minute. In validating this search algorithm, perfect agreement was found in 92% (κ = 0.92) of patients, with 99% agreement occurring within one minute.ConclusionsThe use of an electronic search strategy resulted in highly accurate extraction of mechanical ventilation initiation in the ICU. The search algorithm of mechanical ventilation initiation is highly efficient and reliable and can facilitate both clinical research and patient care management in a timely manner.

Intensive care unit readmission prevention checklist: is it worth the effort?

RATIONALE, AIMS AND OBJECTIVES Checklists have been adopted by various institutions to improve patient outcomes. In particular, readmission prevention checklists may be of potential value to improve patient care and reduce medical costs. As a result, a prior quality improvement study was conducted to create an intensive care unit readmission prevention checklist. The previous pilot demonstrated zero readmissions when the readmission prevention checklist was utilized but yielded low compliance (30%). Thus, a subsequent quality initiative was undertaken to refine the readmission prevention checklist with the primary aim of improved compliance while maintaining a reduced readmission rate that was observed with the original quality improvement study. METHOD A single-centre, cross-sectional study for assessing baseline data and a prospective observational study to assess the effectiveness of a refined readmission prevention checklist tool in a 20-bed tertiary medical-surgical intensive care unit at an academic medical centre in Rochester, MN was conducted. Medical patients admitted through the emergency department, upon direct transfer from outside facility, and post-operative surgical patients at our institution were included. A refined readmission prevention checklist tool was administered during an 8-week pilot period for medical and post-operative surgical patients. RESULTS The refined readmission prevention checklist resulted in an even lower compliance (10.5%) from the initial phase likely resulting from utilization of a paper readmission prevention checklist in an electronic medical environment. Moreover, the refined readmission prevention checklist demonstrated a 22% unplanned readmission rate for patients in which the tool was utilized. CONCLUSIONS In conclusion, the findings of the current quality improvement study may serve to rethink the process of health care delivery that applies paper tools in an electronic medical environment.

Elevated Modified Shock Index Within 24 Hours of ICU Admission Is an Early Indicator of Mortality in the Critically Ill

Purpose: To assess whether exposure to modified shock index (MSI) in the first 24 hours of intensive care unit (ICU) admission is associated with increased in-hospital mortality. Methods: Adult critically ill patients were included in a case–control design with 1:2 matching. Cases (death) and controls (alive) were abstracted by a reviewer blinded to exposure status (MSI). Cases were matched to controls on 3 factors—age, end-stage renal disease, and ICU admission diagnosis. Results: Eighty-three cases and 159 controls were included. On univariate analysis, lorazepam administration (odds ratio [OR]: 5.75, confidence interval [CI] = 2.28-14.47; P ≤ .01), shock requiring vasopressors (OR: 3.62, CI = 1.77-7.40; P ≤ .01), maximum MSI (OR: 2.77 per unit, CI = 1.63-4.71; P ≤ .001), and elevated acute physiologic and chronic health evaluation (APACHE) III score at 1 hour (OR: 1.41 per 10 units, CI = 1.19-1.66; P ≤ .001) were associated with mortality. Maximum MSI (OR: 1.93 per unit, CI = 1.07-3.48, P = .03) and APACHE III score at 1 hour (OR: 1.29 per 10 units, CI = 1.09-1.53; P = .003) remained significant with mortality in the multivariate analysis. The optimal cutoff point for high MSI and mortality was 1.8. Conclusion: Critically ill patients who demonstrate an elevated MSI within the first 24 hours of ICU admission have a significant mortality risk. Given that MSI is easily calculated at the bedside, clinicians may institute interventions earlier which could improve survival.

Improving the Quality of Handoffs in Patient Care Between Critical Care Providers in the Intensive Care Unit.

With the ever-increasing adoption of shift models for intensive care unit (ICU) staffing, improving shift-to-shift handoffs represents an important step in reducing medical errors. The authors developed an electronic handoff tool integrated within the existing electronic medical record to improve handoffs in an adult ICU. First, stakeholder (staff intensivists, fellows, and nurse practitioners/physician assistants) input was sought to define what elements they perceived as being essential to a quality handoff. The principal outcome measure of handoff accuracy was the concordance between data transmitted by the outgoing team and data received by the incoming team (termed as agreement). Based on stakeholder input, the authors developed the handoff tool and provided regular education on its use. Handoffs were observed before and after implementation of the tool. There was an increase in the level of agreement for tasks and other important data points handed off without an increase in the time required to complete the handoff.

Etomidate: to use or not to use for endotracheal intubation in the critically ill?

Endotracheal intubation is frequently performed in the intensive care unit (ICU). It can be life-saving for many patients who present with acute respiratory distress. However, it is equally associated with complications that may lead to unwanted effects in this patient population. According to the literature, the rate of complications associated with endotracheal intubation is much higher in an environment such as the ICU as compared to other, more controlled environments (i.e., operating room). Thus, the conduct of performing such a procedure needs to be accomplished with the utmost care. To facilitate establishment of the breathing tube, sedation is routinely administered. Given the tenuous hemodynamic status of the critically ill, etomidate was frequently chosen to blunt further decreases in blood pressure and/or heart rate. Recently however, reports have demonstrated a possible association with the use of etomidate for endotracheal intubation and mortality in the critically ill. In addition, this association seems to be predominantly in patients diagnosed with sepsis. As a result, some have advocated against the use of this medication in septic patients. Due to the negative associations identified with etomidate and mortality, several investigators have evaluated potential alternatives to this solution (e.g., ketamine and ketamine-propofol admixture). These studies have shown promise. However, despite the evidence against using etomidate for endotracheal intubation, other studies have demonstrated no such association. This leaves the critical care clinician with uncertainty regarding the best sedative to administer in this patient population. The following editorial discusses current evidence regarding etomidate use for endotracheal intubation and mortality. In particular, we highlight a recent article with the largest population to date that found no association between etomidate and mortality in the critically ill and illustrate important findings that the reader should be aware of regarding this article.

Comparison of Ocular Ultrasonography and Magnetic Resonance Imaging for Detection of Increased Intracranial Pressure

Background/aims To evaluate and compare the performance of ocular ultrasonography (US) and magnetic resonance imaging (MRI) for detecting increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH). Methods Twenty-two patients with papilledema from IIH and 22 with pseudopapilledema were prospectively recruited based on funduscopic and clinical findings. Measurements of optic nerve sheath diameters (ONSDs) 3 mm behind the inner sclera were performed on B-scan US and axial T2-weighted MRI examinations. Pituitary-to-sella height ratio (pit/sella) was also calculated from sagittal T1-weighted MRI images. Lumbar puncture was performed in all patients with IIH and in five patients with pseudopapilledema. Results Average US and MRI ONSD were 4.4 (SD ± 0.7) and 5.2 ± 1.4 mm for the pseudopapilledema group and 5.2 ± 0.6 and 7.2 ± 1.6 mm for the papilledema group (p < 0.001). Average MRI pit/sella ratio was 0.7 ± 0.3 for the pseudopapilledema group and 0.3 ± 0.2 for the papilledema group (p < 0.001). Based on receiver-operator curve analysis, the optimal thresholds for detecting papilledema are US ONSD > 4.8 mm, MRI ONSD > 6.0 mm, and MRI pit/sella < 0.5. Combining a dilated US ONSD or MRI ONSD with a below-threshold MRI pit/sella ratio yielded a sensitivity of 73% and specificity of 96% for detecting IIH. Adding the US ONSD to the MRI ONSD and pit/sella ratio only increased the sensitivity by 5% and did not change specificity. Conclusion US and MRI provide measurements of ONSD that are well-correlated and sensitive markers for increased ICP. The combination of the ONSD and the pit/sella ratio can increase specificity for the diagnosis of IIH.