The use of an electronic medical record based automatic calculation tool to quantify risk…

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Respiratory impact of paracentesis in cirrhotic patients with acute lung injury.
J Crit Care. 2011 Jun;26(3):257-61
Authors: Levesque E, Hoti E, Jiabin J, Dellamonica J, Ichai P, Saliba F, Azoulay D, Samuel D
Abstract
…

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Protein C as an early biomarker to distinguish pneumonia from sepsis.
J Crit Care. 2011 Jun;26(3):330.e9-12
Authors: Gutovitz S, Papa L, Jimenez E, Falk J, Wieman L, Sawyer S, Giordano P
Abstract
PURPOSE: Patie…

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Risk factors and mortality of nosocomial infections of methicillin-resistant Staphylococcus aureus in an intensive care unit.
J Crit Care. 2011 Feb;26(1):82-8
Authors: Wang FD, Chen YY, Chen TL, Lin YT, Fung CP
Methici…

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Ultrasound-guided peripheral intravenous access in the intensive care unit.

J Crit Care. 2010 Sep;25(3):514-9

Authors: Gregg SC, Murthi SB, Sisley AC, Stein DM, Scalea TM

Central venous catheters continue to be a popular means of maintaining vascular access in surgical intensive care units despite well-described complications. With edema, obesity, and difficult to visualize veins potentially affecting the surgically ill, inability to obtain peripheral intravenous (PIV) access may hinder the clinician’s ability to avoid the use of central lines. With ultrasound gaining increased popularity for obtaining vascular access, we evaluated its utility in ultrasonagraphically placing PIV catheters for the purposes of either avoiding central venous access or removing central venous catheters.

PMID: 19836193 [PubMed - indexed for MEDLINE]

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Hospitalist bed management effecting throughput from the emergency department to the intensive care unit.

J Crit Care. 2009 Oct 12;

Authors: Howell E, Bessman E, Marshall R, Wright S

RATIONALE: Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes. OBJECTIVE: To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the "active bed management" (ABM) intervention. METHODS: A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow. MEASUREMENT: Throughput time for patients presenting to the ED requiring ICU admission was analyzed. MAIN RESULTS: The ED census was higher during the intervention period as compared with the control period, 17 573 versus 16 148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (+/-14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P < .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant. CONCLUSION: Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety.

PMID: 19828284 [PubMed - as supplied by publisher]

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Low-molecular-weight heparin thromboprophylaxis in medical-surgical critically ill patients: a systematic review.

J Crit Care. 2009 Jun;24(2):197-205

Authors: Ribic C, Lim W, Cook D, Crowther M

PURPOSE: The study aimed to systematically review the effect of low-molecular-weight heparin (LMWH) thromboprophylaxis in medical-surgical critically ill patients in the intensive care unit. METHODS: In duplicate and independently, we searched for relevant articles using MEDLINE and EMBASE; we also contacted experts and reviewed reference lists. For included studies, we abstracted data on study and patient characteristics, LMWH use, clinical outcomes (venous thromboembolism [VTE], bleeding, and mortality), laboratory outcomes (anti-Xa levels and thrombocytopenia), and methodological quality. RESULTS: We included 8 prospective cohort studies and 1 randomized trial, with a total of 629 patients. Eight studies (n = 406 patients) reported anti-Xa levels and only 3 studies (n = 240 patients) reported on at least one clinical outcome. Low-molecular-weight heparin does not appear to bioaccumulate based on repeated measurements of trough anti-Xa levels. Thrombocytopenia occurred in 9.3% of patients receiving LMWH; heparin-induced thrombocytopenia was not reported. In studies reporting clinical outcomes, the frequency of VTE in patients receiving LMWH ranged from 5.1% to 15.5%, bleeding complications ranged from 7.2% to 23.1%, and mortality ranged from 1.4% to 7.4%. CONCLUSIONS: Low-molecular-weight heparin may be effective for thromboprophylaxis in medical-surgical critically ill patients, but no trials have compared LMWH against an alternative active strategy; thus, LMWH cannot be recommended routinely. Trials testing LMWH thromboprophylaxis are required, which examine patient-important end points such as the incidence and clinical consequences of VTE, bleeding, heparin-induced thrombocytopenia, and mortality.

PMID: 19327323 [PubMed - indexed for MEDLINE]

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Management of venous thromboembolism in the intensive care unit.

J Crit Care. 2009 Jun;24(2):185-91

Authors: Pastores SM

Venous thromboembolism, manifested as either deep venous thrombosis or pulmonary embolism (PE), is a major cause of morbidity and mortality in patients admitted to the intensive care unit. Clinically, PE may present as massive thromboembolism associated with cardiogenic shock or may be asymptomatic, as may occur with anatomically small emboli without hemodynamic or respiratory compromise. The management of venous thromboembolism in the critically ill patient can be exceedingly complex. The main treatment objectives are the prevention of recurrent PE and, in case of hemodynamic compromise, definitive therapy for deep venous thrombosis or PE involving removal of thrombus. Prevention of recurrent PE is accomplished with anticoagulation and/or placement of an inferior vena cava filter. Definitive therapy involves thrombolysis and surgical or catheter embolectomy. Fluid and vasoactive therapy with norepinephrine may be indicated for refractory hypotension in patients with massive PE.

PMID: 19501307 [PubMed - indexed for MEDLINE]

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Changes in internal medicine residents’ attitudes about resuscitation after cardiac arrest over a decade.

J Crit Care. 2009 Mar;24(1):141-4

Authors: Deep KS, Griffith CH, Wilson JF

BACKGROUND: Resident physicians’ beliefs about cardiopulmonary resuscitation (CPR) may impact their communication with patients about end-of-life care. We sought to understand how these perceptions and experiences have changed in the past decade because both medical education and American society have focused more on this domain. METHOD: We surveyed 2 internal medicine resident cohorts at a large academic medical center in 1995 and 2005. Residents were asked of their beliefs about survival after CPR, perceived patient understanding, and regret after attempted resuscitation. Residents in 2005 reported more numerical experience with CPR. Current internal medicine residents are more optimistic than the 1995 cohort about survival after an inpatient cardiac arrest. They believe that far fewer patients and families understand resuscitation but report less regret about attempting to resuscitate patients. CONCLUSIONS: These pilot data reveal potential changes in the attitudes of resident physicians toward CPR. The perceived poor understanding among decision makers calls into question the standard of informed consent. Despite this, residents report less regret leading one to ask what factors may underlie this response.

PMID: 19272550 [PubMed - indexed for MEDLINE]

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Utility of Gram stain in the clinical management of suspected ventilator-associated pneumonia. Secondary analysis of a multicenter randomized trial.

J Crit Care. 2008 Mar;23(1):74-81

Authors: Albert M, Friedrich JO, Adhikari NK, Day AG, Verdant C, Heyland DK,

PURPOSE: Gram stains of endotracheal aspirates (EA) and bronchoalveolar lavages (BAL) may guide empiric antibiotic therapy in critically ill patients with suspected ventilator-associated pneumonia (VAP). Previous studies differ regarding the ability of the Gram stain to predict final culture results. The aim of the present study was to evaluate the relationship between EA or BAL Gram stains and final culture results in intensive care unit patients with a suspected VAP. MATERIAL AND METHODS: We retrospectively analyzed data from the Canadian multicenter VAP study to correlate EA or BAL Gram stain and final culture results. We categorized Gram stains as Gram positive (GP) and Gram negative (GN) if any GP or GN organisms respectively were seen on staining. Cultures were considered “positive” if they yielded pathogenic organisms on final results. RESULTS: Seven hundred forty patients were enrolled in the study; 35 did not have a Gram stain done leaving 350 BALs and 355 EAs from 705 patients. Pooling BAL and EA results, we found the overall agreement between Gram stain class and pathogenic bacteria culture results to be poor (kappa = 0.36; 95% CI, 0.31-0.40). Among specimens with Gram stains showing no organisms, 99 (30%) of 331 grew pathogenic organisms. Among specimens with Gram stains showing no GN organisms, 113 (25%) of 452 grew pathogenic GN organisms. Among specimens with Gram stains showing no GP organisms, 45 (11%) of 428 grew pathogenic GP organisms. CONCLUSIONS: Gram stains performed for clinically suspected VAP poorly predict the final culture result and thus have a limited role in guiding initial empiric antibiotic therapy in such patients.

PMID: 18359424 [PubMed - indexed for MEDLINE]

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