Yonatan Y. Greenstein

Effectiveness of a Critical Care Ultrasonography Course

Background Widespread use of critical care ultrasonography (CCUS) for the management of patients in the ICU requires an effective training program. The effectiveness of national and regional CCUS training courses is not known. This study describes a national‐level, simulation‐based, 3‐day CCUS training program and evaluates its effectiveness. Methods Five consecutive CCUS courses, with a total of 363 people, were studied. The 3‐day CCUS training program consisted of didactic lectures, ultrasonography interpretation sessions, and hands‐on modules with live models. Thoracic, vascular, and abdominal ultrasonography were taught in addition to goal‐directed echocardiography. Learners rotated between hands‐on training and interpretation sessions. The teacher‐to‐learner ratio was 1:3 during hands‐on training. Interpretation sessions were composed of interactive small groups that reviewed normal and abnormal ultrasonography images. Learners completed a video‐based examination before and after completion of the courses. Hands‐on image acquisition skills were tested at the completion of the course. Results Average scores on the pretest and posttest were 57% and 90%, respectively (P < .001). The average score on the hands‐on test was 86%. Learners aged 20 to 39 years compared with learners ≥ 40 years old scored better on the pretest (64% vs 51%; P < 0.001), posttest (91% vs 88%; P < .010), and hands‐on test (90% vs 82%; P < .001). Conclusions Learners demonstrated a significant improvement in written test scores that assessed cognitive and image interpretation abilities. In addition, they demonstrated acquisition of practical skills as evidenced by high scores during hands‐on testing. Further studies are needed to determine if a simulation‐based CCUS course will translate into effective clinical practice and to measure the durability of training. This 3‐day course is an effective method to train large groups of critical care clinicians in the skills requisite for CCUS (image acquisition and image interpretation).

A Serious Adult Intraosseous Catheter Complication and Review of the Literature.

Objective: Current guidelines recommend the use of intraosseous access when IV access is not readily attainable. The pediatric literature reports an excellent safety profile, whereas only small prospective studies exist in the adult literature. We report a case of vasopressor extravasation and threatened limb perfusion related to intraosseous access use and our management of the complication. We further report our subsequent systematic review of intraosseous access in the adult population. Data Sources: Ovid Medline was searched from 1946 to January 2015. Study Selection: Articles pertaining to intraosseous access in the adult population (age greater than or equal to 14 years) were selected. Search terms were “infusion, intraosseous” (all subfields included), and intraosseous access” as key words. Data Extraction: One author conducted the initial literature review. All authors assessed the methodological quality of the studies and consensus was used to ensure studies met inclusion criteria. Data Synthesis: The case of vasopressor extravasation was successfully treated with pharmacologic interventions, which reversed the effects of the extravasated vasopressors: intraosseous phentolamine, topical nitroglycerin ointment, and intraarterial verapamil and nitroglycerin. Our systematic review of the adult literature found 2,332 instances of intraosseous insertion. A total of 2,106 intraosseous insertion attempts were made into either the tibia or the humerus; 192 were unsuccessful, with an overall success rate of 91%. Five insertions were associated with serious complications. A total of 226 insertion attempts were made into the sternum; 54 were unsuccessful, with an overall success rate of 76%. Conclusions: Intraosseous catheter insertion provides a means for rapid delivery of medications to the vascular compartment with a favorable safety profile. Our systematic literature review of adult intraosseous access demonstrates an excellent safety profile with serious complications occurring in 0.3% of attempts. We report an event of vasopressor extravasation that was potentially limb threatening. Therapy included local treatment and injection of intraarterial vasodilators. Intraosseous access complications should continue to be reported, so that the medical community will be better equipped to treat them as they arise.

Goal-directed transthoracic echocardiography during advanced cardiac life support: A pilot study using simulation to assess ability

Introduction Goal-directed echocardiography (GDE) is used to answer specific clinical questions that provide invaluable information to physicians managing a hemodynamically unstable patient. We studied perception and ability of house staff previously trained in GDE to accurately diagnose common causes of cardiac arrest during simulated advanced cardiac life support (ACLS); we compared their results with those of expert echocardiographers. Methods Eleven pulmonary and critical care medicine fellows, 7 emergency medicine residents, and 5 cardiologists board certified in echocardiography were enrolled. Baseline ability to acquire 4 transthoracic echocardiography views was assessed, and participants were exposed to 6 simulated cardiac arrests and were asked to perform a GDE during ACLS. House staff performance was compared with the performance of 5 expert echocardiographers. Results Average baseline and scenario views by house staff were of good or excellent quality 89% and 83% of the time, respectively. Expert average baseline and scenario views were always of good or excellent quality. House staff and experts made the correct diagnosis in 68% and 77% of cases, respectively. On average, participants required 1.5 pulse checks to make the correct diagnosis. Of house staff, 94% perceived this study as an accurate assessment of ability. Conclusions In an ACLS-compliant manner, house staff are capable of diagnosing management-altering pathologies the majority of the time, and they reach similar diagnostic conclusions in the same amount of time as expert echocardiographers in a simulated cardiac arrest scenario.

Defining a Ventilation Strategy for Flexible Bronchoscopy on Mechanically Ventilated Patients in the Medical Intensive Care Unit

Background: Flexible bronchoscopy (FB) in intubated patients on mechanical ventilation increases airway resistance. During FB, two ventilatory strategies are possible: maintaining tidal volume (VT) while maintaining baseline CO2 or allowing reduction of VT. The former strategy carries risk of hyperinflation due to expiratory flow limitation with FB. The aim of the authors was too study end expiratory lung volume (EELV) during FB of intubated subjects while limiting VT. Methods: We studied 16 subjects who were intubated on mechanical ventilation and required FB. Changes in EELV were measured by respiratory inductance plethysmography. Ventilator mechanics, EELV, and arterial blood gases, were measured. Results: FB insertions decreased EELV in 64% of cases (−325±371 mL) and increased it in 32% of cases (65±59 mL). Suctioning decreased EELV in 76% of cases (−120±104 mL) and increased it in 16% of cases (29±33 mL). Respiratory mechanics were unchanged. Pre-FB and post-FB, PaO2 decreased by 61±96 mm Hg and PaCO2 increased by 15±7 mm Hg. Conclusions: There was no clinically significant increase in EELV in any subject during FB. Decreases in EELV coincided with FB-suctioning maneuvers. Peak pressure limiting ventilation protected the subject against hyperinflation with a consequent, well-tolerated reduction in VT, and hypercapnea. Suctioning should be limited, especially in patients vulnerable to derecruitment effect.

A man in his 50s with septic shock from an occult source.

A previously healthy man in his 50s presented to an ED complaining of a 1-week history of generalized malaise, weakness, subjective fevers, chills, decreased appetite, and nonbloody diarrhea. He was given a diagnosis of a viral illness and discharged with acetaminophen and ibuprofen. His symptoms continued, and follow-up with his primary physician revealed an elevated serum creatinine level (5.84 mg/dL) from a previously normal baseline. He was referred to the ED.

Adequacy of chest compressions performed by medical housestaff.

Abstract Background: Chest compressions (CCs) are a critical part of cardiopulmonary resuscitation. We studied the presence and duration of adequate CCs performed by medical housestaff, and correlated our findings with gender and body mass index. Methods: Fifty-eight first-postgraduate-year medical housestaff performed CCs on a computerized patient simulator equipped with a calibrated CC measurement device. Following initial testing, subjects were trained to perform adequate CCs. Subjects were retested 2 weeks later. Presence and duration of adequate CCs were measured during a 120-second endurance test. Results: Before training, 14/28 (50%) of the male housestaff performed adequate CCs and 0/30 (0%) of the female housestaff performed adequate CCs. After training, 25/28 (89%) of the male housestaff and 16/30 (53%) of the female housestaff performed adequate CCs. Body mass index and height were not related to adequacy of CCs. After training, 7/28 (25%) of the male subjects and 1/30 (3%) of the female subjects were able to maintain adequate CCs for 120 seconds. Conclusions: Training housestaff on a patient simulator is an effective means of improving the adequacy of CCs. Despite training, a significant number of women were unable to perform adequate CCs compared with men; body mass index and height were not determining factors. Very few housestaff were able to sustain 120 seconds of adequate CCs, despite training.