Richard H. Savel

The iCritical Care Podcast: A Novel Medium for Critical Care Communication and Education

Podcasting is a recent creation combining old and new technologies allowing rapid, inexpensive delivery of media content (primarily audio) to the end user, both via the desktop environment and personal media players. The authors group (the Society of Critical Care Medicine) saw the educational and communication potential for the podcasting concept, and have successfully designed and implemented the first podcast of a national medical society. As of this writing, there are an average of (mean +/- SD) 664 +/- 290 total downloads per podcast, and their podcast feed has been hit over 68,000 times in its first seven months. In this manuscript, the authors provide documentation of their successful endeavor, as well as a structured framework for other organizations to create similar products.

Association of super-super-obesity and male gender with elevated mortality in patients undergoing the duodenal switch procedure.

Background: Previous studies have reported that risk factors for elevated mortality after Roux-en-Y gastric bypass include male gender, as well as a very elevated BMI. The present study was aimed at determining whether these same risk factors applied to patients undergoing the duodenal switch (DS) operation. Materials and Methods: A retrospective chart review was performed of a cohort of 385 patients who underwent DS. The 30-day mortality of super-superobese (SSO) patients [BMI ≥60 kg/m2 (n=102)] was compared with the mortality of the super- and morbidly obese (SMO) patients [35<BMI<60 kg/m2 (n=283)]. Results: Overall mortality in SSO patients was 7.8% (8/102), compared with 0% (0/283) in SMO patients undergoing the same procedure (P<0.001). When a gender-based subgroup analysis was performed in the SSO patients, men had a 16.7% mortality (7/42) while women had only a 1.7% (1/60) mortality. Conclusions: In this study of patients undergoing DS, being SSO – specifically SSO men – was associated with increased mortality. Further studies will be needed to better determine the precise mechanism of these risk factors leading to such an elevation in mortality. Until then, caution should be exercised before performing DS in male patients with BMI ≥60 kg/m2.

Beneficial Effects of Humidified, Warmed Carbon Dioxide Insufflation during Laparoscopic Bariatric Surgery: a Randomized Clinical Trial

Background: Recent data has shown that the use of warmed, humidified carbon dioxide (CO2) insufflation during laparoscopic surgery may be associated with better outcomes. Methods: We performed a randomized, doubleblind, prospective controlled clinical trial of 30 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Patients were randomized into 2 groups. The first group (group 1, n=15) received standard (dry, room temperature) CO2 for insufflation during the surgery, while the second group (group 2, n=15) received warmed (35°C) and humidified (95%) CO2. Patients received postoperative analgesia from morphine delivered via a patient-controlled analgesia (PCA) pump. Pain scores (on a scale of 0 to 10, 0 being no pain and 10 being the worst pain) were measured postoperatively at 3 h, 6 h, 1 day and 2 days. The amount of morphine that was delivered through the PCA was also measured at the same time intervals. Operating-room (OR) time, core temperature, and total hospital length of stay were documented. Results: Postoperative pain as documented by pain scores and narcotic usage were not statistically different in the 2 groups. We demonstrated a statistically significant difference (mean±SD) in OR time (76±16 min vs 101±34 min, P=0.02), total hospital length of stay (3.2±.4 days vs 4.0±.9 days, P=0.01) and end-of-case core temperature (36.2±.5°C vs 35.7±.6°C, P=0.02) in group 2 compared with group 1. Conclusion: The use of warmed, humidified CO2 insufflation in bariatric patients undergoing LRYGBP was not associated with any significant benefit with regards to postoperative pain.

Protective effects of low tidal volume ventilation in a rabbit model of Pseudomonas aeruginosa-induced acute lung injury

ObjectiveTo determine whether low “stretch” mechanical ventilation protects animals from clinical sepsis after direct acute lung injury with Pseudomonas aeruginosa as compared with high “stretch” ventilation. DesignProspective study. SettingExperimental animal laboratory. SubjectsTwenty-seven anesthetized and paralyzed rabbits. InterventionsP. aeruginosa (109 colony forming units) was instilled into the right lungs of rabbits that were then ventilated at a tidal volume of either 15 mL/kg (n = 11) or 6 mL/kg (n = 7) for 8 hrs. Control animals were ventilated at a tidal volume of either 15 mL/kg (n = 4) or 6 mL/kg (n = 5) for 8 hrs, but an instillate without bacteria was used. A positive end-expiratory pressure of 3–5 cm H2O was used for all experiments. Radiolabeled albumin was used as a marker of alveolar epithelial permeability. Measurements and Main Results Hemodynamics, arterial blood gas determination, alveolar permeability, wet-to-dry ratios on lungs, and time course of bacteremia were determined. When final values were compared with the values at the beginning of the experiment, there were significant decreases in mean arterial pressure (from 104 ± 15 to 57 ± 20 mm Hg), pH (from 7.46 ± 0.04 to 7.24 ± 15), Pao2 (from 528 ± 35 to 129 ± 104 torr [70.4 ± 4.7 to 17.2 ± 13.9 kPa]), and temperature (from 38.2 ± 1 to 36.2 ± 1.2°C) in the high tidal volume group, whereas no significant differences were found in the low tidal volume group. Decreased alveolar permeability was shown in the low tidal volume group, as was decreased extravascular lung water in the uninstilled lung in the low tidal volume group (12.7 ± 2.5 vs. 4.3 ± 0.45 g H2O/g dry lung). No noteworthy difference was noted in the time course of bacteremia, although there was a trend toward earlier bacteremia in the high tidal volume group. ConclusionsIn our animal model of P. aeruginosa-induced acute lung injury, low tidal volume ventilation was correlated with improved oxygenation, hemodynamic status, and acid-base status as well as decreased alveolar permeability and contralateral extravascular lung water.

Continuous Infusion of Intraperitoneal Bupivacaine after Laparoscopic Surgery: A Randomized Controlled Trial

BackgroundA standard approach for postoperative analgesia in laparoscopic surgery is to infiltrate the incisions with local anesthetic in combination with systemic opioids. The intraperitoneal introduction of local anesthetic in this setting has the potential to provide appropriate analgesia without the side effects of systemic opioids. We performed a randomized clinical trial of the On-Q pump delivery system to determine the safety and efficacy of this device for this novel purpose.MethodsThirty patients undergoing laparoscopic adjustable gastric banding were randomly assigned to one of two groups. The treatment group received On-Q pump systems filled with 0.375% bupivacaine, while the control group received pumps filled with 0.9% normal saline. The pump’s catheter was introduced intraperitoneally, and bupivacaine or saline was then delivered for the first 48xa0h after surgery. Patient’s subjective pain scores were evaluated at preset intervals. In addition, shoulder pain, morphine requirements, and anti-emetic requirements were tabulated.ResultsA statistically significant decrease in patient’s subjective reports of pain by visual analog score was noted in the On-Q group 1.8u2009±u20091.93 vs. control 3.5u2009±u20092.4, pu2009<u20090.046 and remained significant until the end of the study (48xa0h). No statistical difference was noted in shoulder pain, morphine requirements, or anti-emetic requirements at any time point.ConclusionOur trial was able to provide evidence of significant reduction in postoperative pain as measured by subjective pain scores with the use of continuous intraperitoneal bupivacaine using the On-Q pain pump system. Further investigation is warranted to evaluate the cost effectiveness of this technique.

Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research.

Checklists have been recently promulgated as a method to enhance patient safety and improve outcomes for critically ill patients. Specifically, recent work performed by researchers from the Johns Hopkins Medical Institutions has demonstrated that the addition of checklists to usual care in the intensive care unit is associated with a decrease in the incidence of catheter-related bloodstream infections. Initially evaluated at the institutional level, this effort has been successfully expanded to the state level as part of the Michigan Keystone Project. Although this work has recently received significant positive attention in the lay press, the Office for Human Research Protections—as they felt that this was a research project requiring Institutional Review Board approval and informed consent—put the data collection on hold for lack of approval by the Institutional Review Board at the participating hospitals in Michigan as well as for not having obtained informed consent from each patient and clinician involved in the project. This article documents the recent events surrounding the Keystone Project and the response to the actions taken by the Office for Human Research Protections in the lay press and the new media (Internet and blogs), articulates how a determination can be made if a project is quality-improvement, human-subjects research, or both, and proposes some solutions to create a structured approach to this kind of research in the future.

Use of Drotrecogin Alfa (Activated) in Bariatric Surgery Patients with Severe Sepsis Syndrome: Experience in an Urban Community Teaching Hospital

Background: Severe sepsis syndrome (SSS) and septic shock have an associated mortality ranging from 31 to 60%. Drotrecogin alfa (activated), activated protein C (APC), has been shown in a recent trial to decrease mortality from 44 to 31% in patients with SSS and a high risk of death. We present 3 patients who developed SSS after bariatric surgery and were treated with APC as part of comprehensive therapy for sepsis. Methods: At our institution, patients must have SSS plus an APACHE II score ≥ 25 in order to receive APC. JL is a 43-year-old man who developed SSS (APACHE II score 26) after Roux-en-Y gastric bypass. ML is a 33-year-old man who developed SSS (APACHE II=28) because of a distal obstruction 2.5 years after gastric bypass surgery. TQ was a 35-year-old man who developed SSS (APACHE II=35) in the setting of laparoscopic banding. Results: After receiving 90% of the 96-hour infusion, JL developed ecchymoses and a decrease in his platelet count; thus, the drug was stopped. ML received a full 96-hour infusion. Both patients made a full recovery from their SSS and were successfully discharged from the hospital. TQ developed septic shock and expired despite all efforts. Conclusion: Weight alone should not be considered a contraindication to the use of APC. Close coordination between the intensivist and surgeon is recommended for bariatric surgery patients with SSS, so that a rapid determination can be made as to the patients risk of death and eligibility to receive APC.

Successful Thrombolysis of Submassive Pulmonary Embolism after Bariatric Surgery: Expanding the Indications and Addressing the Controversies

Background: Venous thromboembolic (VTE) disease is a much-feared complication of bariatric surgery. The most common unexpected cause of death in the morbidly obese patient is pulmonary embolism (PE). Recent data supports the expanded use of systemic thrombolytics in hemodynamically stable patients with PE and echocardiographic evidence of right ventricular (RV) dysfunction. Methods: We report a morbidly obese 28-year-old female who presented with dyspnea 3 weeks following bariatric surgery. The patient developed a submassive PE, despite being on low molecular weight (LMW) heparin (dalteparin) postoperatively. The patient was admitted to the surgical intensive care unit of an urban community teaching hospital and underwent successful thrombolysis. Results: Although the patient was not hypotensive, she was tachycardic and highly symptomatic. Spiral CT scanning revealed a large saddle embolism. Transthoracic echocardiography revealed moderate-to-severe acute RV dysfunction with paradoxical septal motion. The patient was started on IV heparin followed by an infusion of alteplase 100 mg IV over 2 hours. She had no mental status changes during the infusion or evidence of hemorrhage. She had a rapid improvement of her symptoms. Repeat CT scanning revealed marked resolution of the PE. She was discharged home in excellent condition. Conclusion: To our knowledge, this is the first report of systemic thrombolysis for a submassive PE after bariatric surgery in a hemodynamically stable patient with RV dysfunction. Given the high incidence and morbidity of VTE disease in this population, and the expanding indications for thrombolytic therapy, successful cases such as these should be documented.

The unplanned intensive care unit admission

The optimal timing for consultation and admission to an intensive care unit (ICU) is difficult to define. Early recognition of critical illness, ideally in the emergency department, with prompt admission to an ICU should result in improved outcomes. But in reality, delays do occur; beds are scarce, and, at times, critical illness or impending deterioration is unrecognized. A large study by Chalfin et al [1] demonstrated that even short delays in transfer of critically ill patients from the emergency department to the ICU resulted in increasedmortality and length of stay. Using the Project IMPACT database,more than 50000patients in 120 heterogeneous ICUs and hospital centers were evaluated. Boarding in the emergency department for 6 hours ormore before transfer to ICU increased in-hospital mortality by 4.5%. In this issue of Journal of Critical Care, Cohen et al [2] add to the growing literature of “the unplanned ICU admission”: patients requiring ICU transfer shortly after admission to the general wards. This is a unique and important population of patients who have rapid disease progression and decompensation, new onset illness and, at times, potentially may represent mistriage of patients with unrecognized critical illness [3-5]. Similar to delayed transfers, the literature demonstrates that unplanned admissions are associated with worse outcomes and increased mortality [5-7]. In this article, the authors aim to detect the differences between ICU admissions and rejectionswithin 48 hours of admission and, in addition, compare them with patients admitted directly to the ICU from the emergency department. Their outcomes demonstrated an increased length of stay for unplanned admissions without a significant mortality difference between the designated cohorts. With rigorous data collection and chart review, the authorswere able to better characterize the unplanned ICU consultations. The overwhelming majority of consultation was requested by the emergency department (75%), and only a small minority (15%) occurred within 48 hours of ward admission. Emergency department admissions (59% admission rate) had a higher severity of illness and better baseline functional status when compared with rejections. One hundred thirty-four patients were seen as unplanned consults; in alignment with results from similar studies, pulmonary deterioration andworsening sepsis were the leading indicators of consultation and ICU admission [4-6,8]. Ward admissions (49% admission rate) had fewer comorbidities and better functional status when compared with ward rejections, but overall severity of illness was similar. The possibility of initial triage error remains a legitimate concern as the cause of unplanned consultation and need for transfer. As noted by the authors, Bapoje et al [3] found that 19% of unplanned transfers to a medical ICU were associated with preventable errors in care and inappropriate triage. In the current study, the authors believe this to

Video laryngoscopy in the intensive care unit. A clearer view

The Accreditation Council for Graduate Medical Education (ACGME) requires that critical care fellows be trained in endotracheal intubation (1). Not stated by the ACGME, but self-evident, is that critical care trainees achieve competency in intubating patients in the intensive care unit. Compared with elective intubations in the operating room, endotracheal intubation of critically ill patients presents numerous challenges. Urgent or emergent procedures are routine, difficult airways are often encountered, and complications are relatively common (1–3). Although trainees must learn in this high-risk environment, patient safety must be preserved during the training process. Many measures have been recommended to improve the safety of emergency intubations by physicians in training. These include simulation training (4), dedicated airway service rotations, the use of a preintubation checklist, and the adoption of video laryngoscopy (5). Whether and how these commonsense ideas have been adapted by training programs has been largely unknown. In this issue of AnnalsATS, Silverberg and Kory (pp. 1225–1229) survey program directors of U.S. critical care training programs on video laryngoscope use (6). The response rate was modest, at 36%, but there was a broad geographic distribution. The majority of programs represented by the respondents (61%) are university-based. A videolaryngoscope is available in 89% of programs, is used as the primary device in 16%, and is never used in 9%. In the remainder of the programs, the video laryngoscope is used only for difficult intubations or after failure of direct laryngoscopy (32%), or it is used as the primary device by operator choice (32%). The most commonly stated reasons for not using a video laryngoscope were the belief that acquisition of direct laryngoscopy skills are degraded by use of the devices (30%), concern about the cost of the device (9%), lack of faculty members who are capable of training fellows in video laryngoscopy (9%), and the belief that using the video laryngoscope has not been proven to be better than direct laryngoscopy. There is strong evidence to support the use of video laryngoscopy in the intensive care unit. A meta-analysis of nine clinical trials demonstrated that compared with direct laryngoscopy, video laryngoscopy reduced the risk for difficult intubation, decreased the number of Cormack grade 3 or 4 views, decreased esophageal intubation, and increased first-attempt success (7). Although not fully proven, the time for novices to reach basic proficiency with a video laryngoscope appears to be faster than that reported with direct laryngoscopy (8, 9). In addition, when supervising a trainee, the ability of the supervisor to easily see what the trainee is visualizing with the video laryngoscope and to offer real-time corrections is invaluable. There were other important findings in the Silverberg and Kory survey (6). More than half (53%) of programs represented by the respondents graduated fellows who had performed fewer than 50 intubations during their fellowship. Few programs (11%) had fellows who averaged more than 100 intubations. The exact number of endotracheal intubations required for proficiency is not known, but prior studies focused primarily on elective operating room intubations have suggested a number around 50 (10–12). These studies do not take into account the increased variance of emergency intubation, the need for training in the proper use of different backup devices, or the need for training on both direct and video laryngoscopy. From a prior survey of airway management, programs have difficulty training fellows in backup airway devices, with 73% reporting 30 or fewer video laryngoscopic intubations per fellow and 65% reporting 10 or fewer flexible bronchoscopic intubations (13). In the current survey, despite the arguably low numbers of reported intubations achieved, 92% of program directors thought their fellows were comfortable with intubation. Whether this perception is shared by graduating fellows is unclear. Moreover, confidence in a skill is not necessarily strongly correlated with ability (14). Rather than focusing on specific numbers, or relying on reported confidence, competency-based assessment of skills, perhaps using patient simulators, should become more prevalent. Limitations of the study were mostly acknowledged by the authors. First, the authors surveyed program directors, not fellows; the opinions of fellows on their airway training could differ; and the person responsible for airway training at each medical center may not be the program director. Second, there was a relatively low response rate of 36%, and programs more