Thomas E. Grissom

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

The provision of sophisticated critical care beyond the hospital: Lessons from physiology and military experiences that apply to civil disaster medical response

Objective:The provision of sophisticated medical care in an austere environment is challenging. During and after a mass casualty event, it is likely that critical care services will be needed beyond an intensive care unit (ICU) setting. The objective of this article is to explore existing ICU care systems such as military aeromedical transport that may be applicable to disaster medicine and to providing critical care outside of an ICU setting. Results:The U.S. Air Force Critical Care Aeromedical Transport (CCAT) Teams were developed in 1994 in response to an unmet military need for long-range air transport of critically ill and injured patients. This system has transported several thousand ICU patients and is an applicable model for the future development of extrahospital critical care capabilities needed during a disaster. We also discuss civilian aeromedical critical care systems, the types of medical devices used, and their applicability to disaster medical response. Conclusion:The U.S. Air Force CCAT Team program, as well as many civilian critical care air ambulance services, provides a workable starting point for the development of disaster medical critical care response capabilities for disaster medical systems.

Effect of video laryngoscopy on trauma patient survival: A randomized controlled trial

BACKGROUND Many resuscitation scenarios include the use of emergency intubation to support injured patients. New video-guided airway management technology is available, which may minimize the risk to patients from this procedure. METHODS This was a controlled clinical trial conducted in the trauma receiving unit in a university-affiliated urban hospital in which 623 consecutive adult patients requiring emergency airway management were prospectively randomized to intubation with either the direct laryngoscope (DL) or the GlideScope video laryngoscope (GVL) device. RESULTS The primary outcome was survival to hospital discharge. There was no significant difference in mortality between the GVL group (28 [9%] of 303) and the DL group (24 [8%] of 320) (p = 0.43) for all patients. Within a smaller cohort identified retrospectively, there was a higher mortality rate seen in the subgroup of patients with severe head injuries (head Abbreviated Injury Scale [AIS] score > 3) who were randomized to intubation with GVL (22 [30%] of 73) versus DL (16 [14%] of 112) (p = 0.047). Among all patients, median intubation duration in seconds was significantly higher for the GVL group (median, 56; interquartile range, 40–81) than for the DL group (median, 40; interquartile range, 24–68) (p < 0.001). Among those with severe head injuries, median intubation duration in seconds was also significantly higher for the GVL group (median, 74) than for the DL group (median, 65) (p < 0.003). Correspondingly, this group also experienced a greater incidence of low oxygen saturations of 80% or less (27 [50%] of 54 for the GVL group and 15 [24%] of 63 for the DL group; p = 0.004). There were no significant differences between the two groups in first-pass success (80% for GVL and 81% for DL, p = 0.46). CONCLUSION Use of the GlideScope did not influence survival to hospital discharge among all patients and was associated with longer intubation times than direct laryngoscopy. Among the video laryngoscope cohort, a smaller subgroup of severe head injury trauma patients identified retrospectively seemed to be associated with a greater incidence of hypoxia of 80% or less and mortality. LEVEL OF EVIDENCE Therapeutic study, level II.

Anesthetic implications of the renin-angiotensin system and angiotensin-converting enzyme inhibitors

This review is designed to define and update the mechanisms and implications of Renin-Angiotensin system (RAS) activation, as well as the mechanisms and goals of RAS blockade, both in and outside of the operating room. In this way we hope to put into perspective how the RAS fits into the scheme of hemodynamic responses perioperatively and the potential manipulations we have at our disposal for the control of these responses

Titration of intravenous anesthetics for cardioversion: a comparison of propofol, methohexital, and midazolam.

To compare propofol, methohexital, and midazolam administered as titrated infusions for sedation during electrical cardioversion. Design:A prospective, randomized, single-blind comparative study. Setting:Coronary care unit in a military teaching hospital. Patients:Thirty adult patients with atrial fibrillation, atrial flutter, or paroxysmal supraventricular tachycardia. Each patient required electrical cardioversion. Patients were randomized to receive one of the three study drugs. Ten patients composed one drug group. Measurements and Main Results:Demographic variables were similar between groups. Patients were randomized to receive propofol (10 mg/ mL), methohexital (5 mg/mL), or midazolam (0.5 mg/mL) administered at 10 mL/min until the patients failed to follow verbal commands and demonstrated a degradation of the lid response to stimulation. Dose requirements (mean ± SD) were propofol 1.69 ± 0.46 mg/kg, methohexital 1.07 ± 0.34 mg/kg, and midazolam 0.16 ± 0.06 mg/ kg. Hemodynamic assessment at baseline, after induction, after cardioversion, and at recovery demonstrated no difference in mean arterial pressure between the three groups. The time to awakening was significantly prolonged in the group that received midazolam (33 ±11 mins, p < .05) as compared with the times of the groups that received propofol (11 ± 4 mins) and methohexital (9 ± 3 min). Side-effects were similar between groups, with the exception of an increase in pain on injection with propofol and an increased frequency of confusion in those patients receiving midazolam. Recall of the electrical discharges at one hour after the procedure occurred in two patients in the propofol group. In both cases, there were technical problems which caused the duration of the procedure to extend into the anticipated recovery period. Unit dose costs at our institution for a 70-kg patient are: methohexitol,

Critical care considerations in the management of the trauma patient following initial resuscitation

3.14 (500-mg bottle); medazolam,

Bring Out Your Data: The Evolution of the National Anesthesia Clinical Outcomes Registry (NACOR)

14.88 (5-mg vials × 3); and propofol,

The Epidemiology of Critical Care Air Transport Team Operations in Contemporary Warfare

6.60 (200-mg ampule). Conclusions:All three drugs are acceptable choices for use during elective direct-current cardioversion. Titration of the agent results in a total drug dose which is usually less than the typical induction dose. There were no significant differences in the hemodynamic actions of these drugs at any time interval. Both propofol and methohexital proved superior in their ability to provide a more rapid anesthetic onset and recovery as compared with midazolam. Propofol offers the advantage of requiring no premixing or dilution, and it is not a controlled substance, although it does result in more pain on injection. (Crit Care Med 1993; 21:1509–1513)

Effect of halothane on phenylephrine-induced vascular smooth muscle contractions in endotoxin-exposed rat aortic rings.

BackgroundCare of the polytrauma patient does not end in the operating room or resuscitation bay. The patient presenting to the intensive care unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory, cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented.MethodsA non-systematic literature search was conducted using PubMed and the Cochrane Database of Systematic Reviews up to May 2012.Results and conclusionPolytrauma patients with severe shock from hemorrhage and massive tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for “damage control resuscitation” including the use of fixed ratios in the treatment of trauma induced coagulopathy remain controversial. A lack of large, randomized, controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging patients.

Topical hemostatic agents and dressings in the prehospital setting.

Recent healthcare legislation, financial pressures, and regulatory oversight have increased the need to create improved mechanisms for performance measurement, quality management tracking, and outcomesbased research. The Anesthesia Quality Institute (AQI) has established the National Anesthesia Clinical Outcomes Registry (NACOR) to support these requirements for a wide-range of customers including individual anesthesiologists, anesthesia practices, hospitals, and credentialing agencies. Concurrently, the availability of increased digital sources of healthcare data make it possible to capture massive quantities of data in a more efficient and cost-effective manner than ever before. With NACOR, AQI has established a user-friendly, automated process to effectively and efficiently collect a wide-range of anesthesia-related data directly from anesthesia practices. This review will examine the issues guiding the evolution of NACOR as well as some potential pitfalls in its growth and usage. DOI: 10.4018/978-1-4666-2653-9.ch008