Implementation of 24/7 intensivist presence in the SICU: effect on processes of care

BACKGROUND

Staffing of attending intensivists 24 hours per day, 7 days per week (24/7) in the surgical intensive care unit (SICU) has unknown benefits. We hypothesized that 24/7 attending intensivist staffing in the SICU would improve outcomes and processes of care.

METHODS

We retrospectively reviewed 26 months of admissions to our 20-bed SICU, comparing 13 months before and 13 months after addition of an in-house night intensivist to the existing day intensivist with a nighttime on-demand model. Primary outcomes were mortality, complications, SICU length of stay, and ventilator days. Secondary outcomes were use of intensivist-directed ancillary testing and therapies, as well as physician billing (relative value units per full-time equivalent [RVU/FTE]).

RESULTS

A total of 2,829 patients were included: 1,408 before and 1,421 after 24/7 staffing. Baseline characteristics, mortality, complications, ventilation days, ICU and hospital length of stay, and readmission rate were similar between groups (all p > 0.05). Use of blood products and imaging tests (computed tomographic scans) were significantly reduced. Total RVU increased, as did the RVU/FTE ratio.

CONCLUSION

Implementation of 24/7 staffing did not improve SICU morbidity or mortality but was associated with decreased blood product use and fewer axial imaging studies. The RVU/FTE ratio was improved. Overall health care value may be decreased under this model.

LEVEL OF EVIDENCE

Care management study, level IV.

A 5-year observational study of lung-protective ventilation in the operating room: a single-center experience

PURPOSE

We assessed the evolution of lung-protective ventilation strategies during anesthesia and identified factors associated with the selection of a nonprotective ventilation strategy.

METHODS

This retrospective observational study covered a 5-year period from March 2006 to March 2011. It included 45575 adult patients who underwent intubation de novo in the operating room. We considered a tidal volume (VT) greater than 10 mL/kg of ideal body weight (IBW) and/or positive end-expiratory pressure (PEEP) less than 5 cm H2O as not lung protective. We evaluated the use of nonprotective ventilation strategies over time in men and women, by American Society of Anesthesiologists classification, and for elective vs emergent surgery.

RESULTS

Over the duration of the study, there was a significant reduction in the percentage of patients receiving a VT greater than 10 mL/kg IBW (28.5%-16.3%, P < .001), zero PEEP (27.5%-18.2%, P < .001), and VT greater than 10 mL/kg IBW with PEEP less than 5 cm H2O (13.4%-8.0%, P < .001). The odds of receiving nonprotective ventilation were greater for women than for men, in the first year compared with the last year, and for elective compared with emergent surgery.

CONCLUSION

Although use of nonprotective ventilation decreased over time, an important percentage of patients continue to receive nonprotective ventilation.

The ventilator liberation process: update on technique, timing, and termination of tracheostomy

Tracheostomy is one of the most commonly performed procedures in the ICU. Despite the frequency of the procedure, there remains controversy regarding selection of patients who should undergo tracheostomy, the optimal technique, timing of placement and decannulation, as well as impact on outcome associated with the procedure. A growing body of literature demonstrates that percutaneous tracheostomy performed in the ICU is a safe procedure, even in high risk patients. Advances in techniques, together with adjuncts to improve visualization, seem promising and likely to further improve the safety of the technique. Although there was initial enthusiasm in support of early tracheostomy to improve patient outcomes, repeated studies have been unable to produce robust benefits. The question of optimal timing and location of decannulation has not been answered, but there is some reassurance that in aggregate, across a variety of ICUs, patients do not appear to be harmed by transfer to ward with tracheostomy. Future research into techniques, timing, and termination of tracheostomy is warranted.

Altered arterial compliance in hypertensive pregnant women is associated with preeclampsia

BACKGROUND

Vascular alterations are present in pregnant women affected by preeclampsia. In this study, we assessed arterial compliance in women affected by hypertensive disorders of pregnancy. We hypothesized that arterial compliance is reduced in women affected by preeclampsia.

METHODS

Forty-three hypertensive pregnant women undergoing evaluation for preeclampsia were studied. Clinical data about each patient and pregnancy were collected. Large (C1) and small (C2) artery compliance were assessed by radial tonometry, while the patients underwent laboratory tests to diagnose preeclampsia. At the time of delivery, gestational age and newborn data were recorded.

RESULTS

Eighteen women were diagnosed with preeclampsia. C2 levels were lower among preeclamptic versus hypertensive aproteinuric women (mean ± SD, 4.5 ± 1.3 vs 5.9 ± 2.3 mL/mm Hg · 100, P = 0.013, 95% confidence interval [CI] of difference 0.32-2.55), whereas C1 levels did not differ. In the preeclampsia group, C2 levels correlated with urine total protein concentrations measured the same day (Spearman ρ = -0.49, P = 0.047, upper 95% CI -0.01) and with gestational age at first occurrence of hypertension (Spearman ρ = 0.59, P = 0.010, lower 95% CI 0.17). Among singleton gestations, C2 also correlated with newborn birth weight measured at delivery (Spearman ρ = 0.43, P = 0.009, lower 95% CI 0.11). Women who were hypertensive but aproteinuric at the time of compliance assessment, but who subsequently developed preeclampsia (n = 6), had C2 levels similar to those with an early diagnosis of preeclampsia (mean difference 0.37 mL/mm Hg · 100, 95% CI -2.42 to 1.67) and lower C2 levels than women diagnosed with gestational hypertension (P = 0.019, 95% CI 0.33-4.42 mL/mm Hg · 100).

CONCLUSIONS

The noninvasive assessment of arterial elasticity may contribute toward characterization of the nature of the pathophysiology in pregnancy-induced hypertensive disorders. The vascular alterations of the small arteries, as assessed by C2, may reflect the extent of vascular alterations present with preeclampsia.

Global muscle strength but not grip strength predicts mortality and length of stay in a general population in a surgical intensive care unit

BACKGROUND

Paresis acquired in the intensive care unit (ICU) is common in patients who are critically ill and independently predicts mortality and morbidity. Manual muscle testing (MMT) and handgrip dynamometry assessments have been used to evaluate muscle weakness in patients in a medical ICU, but similar data for patients in a surgical ICU (SICU) are limited.

OBJECTIVE

The purpose of this study was to evaluate the predictive value of strength measured by MMT and handgrip dynamometry at ICU admission for in-hospital mortality, SICU length of stay (LOS), hospital LOS, and duration of mechanical ventilation.

DESIGN

This investigation was a prospective, observational study.

METHODS

One hundred ten patients were screened for eligibility for testing in the SICU of a large, academic medical center. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, diagnoses, and laboratory data were collected. Measurements were obtained by MMT quantified with the sum (total) score on the Medical Research Council Scale and by handgrip dynamometry. Outcome data, including in-hospital mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation, were collected for all participants.

RESULTS

One hundred seven participants were eligible for testing; 89% were tested successfully at a median of 3 days (25th-75th percentiles=3-6 days) after admission. Sedation was the most frequent barrier to testing (70.6%). Manual muscle testing was identified as an independent predictor of mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation. Grip strength was not independently associated with these outcomes.

LIMITATIONS

This study did not address whether muscle weakness translates to functional outcome impairment.

CONCLUSIONS

In contrast to handgrip strength, MMT reliably predicted in-hospital mortality, duration of mechanical ventilation, SICU LOS, and hospital LOS.

Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications

BACKGROUND

Emergent intubation is associated with a high rate of complications. Neuromuscular blocking agents are routinely used in the operating room and emergency department to facilitate intubation. However, use of neuromuscular blocking agents during emergent airway management outside of the operating room and emergency department is controversial. We hypothesized that the use of neuromuscular blocking agents is associated with a decreased prevalence of hypoxemia and reduced rate of procedure-related complications.

METHODS

Five hundred sixty-six patients undergoing emergent intubations in two tertiary care centers, Massachusetts General Hospital, Boston, MA, and the University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA, were enrolled in a prospective, observational study. The 112 patients intubated during cardiopulmonary resuscitation were excluded, leaving 454 patients for analysis. All intubations were supervised by attendings trained in Critical Care Medicine. We measured intubating conditions, oxygen saturation during and 5 mins following intubation. We assessed the prevalence of procedure-related complications defined as esophageal intubation, traumatic intubation, aspiration, dental injury, and endobronchial intubation.

RESULTS

The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049). After controlling for the number of intubation attempts and laryngoscopic view, muscle relaxant use is an independent predictor of complications associated with emergency intubation (p = .037), and there is a trend towards improvement of oxygenation (p = .07).

CONCLUSION

The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.

Dexmedetomidine for sedation in the parturient with respiratory failure requiring noninvasive ventilation

Dexmedetomidine is a selective alpha-2 receptor agonist that possesses both sedative and analgesic properties, with minimal respiratory depression. We report the successful administration of dexmedetomidine on a 16-year-old primigravida woman that allowed the patient to tolerate application of bi-level positive airway pressure ventilation in treatment of acute hypoxemic respiratory failure.

The surgical intensive care unit optimal mobility score predicts mortality and length of stay

OBJECTIVES

To test if the surgical intensive care unit optimal mobility score predicts mortality and intensive care unit and hospital length of stay.

DESIGN

Prospective single-center cohort study.

SETTING

Surgical intensive care unit of the Massachusetts General Hospital.

PATIENTS

One hundred thirteen consecutive patients admitted to the surgical intensive care unit.

INVESTIGATIONS

We tested the hypotheses that the surgical intensive care unit optimal mobility score independent of comorbidity index, Acute Physiology and Chronic Health Evaluation II, creatinine, hypotension, hypernatremia, acidosis, hypoxia, and hypercarbia predicts hospital mortality, surgical intensive care unit and total hospital length of stay.

MEASUREMENTS AND MAIN RESULTS

Two nurses independently predicted the patients' mobilization capacity by using the surgical intensive care unit optimal mobility score the morning after admission, whereas a third nurse recorded the achieved mobilization levels of patients at the end of the day. A multidisciplinary expert team measured patients' grip strength and assessed their predicted mobilization capacity independently. Multivariate analysis revealed that the surgical intensive care unit optimal mobility score was the only independent predictor of mortality. Surgical intensive care unit optimal mobility score, hypotension, and hypernatremia (>144 mmol/L) independently predicted intensive care unit length of stay, whereas the surgical intensive care unit optimal mobility score and hypernatremia predicted total hospital length of stay. The Acute Physiology and Chronic Health Evaluation II score was not identified in the multivariate analysis. The surgical intensive care unit optimal mobility score was also a reliable and valid instrument in predicting achieved mobilization levels of patients.

CONCLUSIONS

In surgical critically ill patients presenting without preexisting impairment of functional mobility, the surgical intensive care unit optimal mobility score is a reliable and valid tool to predict mortality and intensive care unit and hospital length of stay.

Use of video laryngoscopy and camera phones to communicate progression of laryngeal edema in assessing for extubation: a case series

Video laryngoscopy has demonstrated utility in airway management. For the present case series, we report the use of video laryngoscopy to evaluate the airway of critically ill, mechanically ventilated patients, as a means to reduce the risk of immediate postextubation stridor by assessing the degree of laryngeal edema. We also describe the use of cellular phone cameras to document and communicate airway edema in using video laryngoscopy for the patients' medical records. We found video laryngoscopy to be an effective method of assessing airway edema, and cellular phone cameras were useful for recording and documenting video laryngoscopy images for patients' medical records.

Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction

BACKGROUND

Procedural sedation is frequently performed in spontaneously breathing patients, but hypnotics and opioids decrease respiratory drive and place the upper airway at risk for collapse.

METHODS

In a randomized, controlled, cross-over, pharmaco-physiologic study in 12 rats, we conducted acute experiments to compare breathing and genioglossus electromyogram activity at equianesthetic concentrations of ketamine, a noncompetitive N-methyl-D-aspartate receptor antagonist that combines potent analgesic with hypnotic action effects, versus propofol. In 10 chronically instrumented rats resting in a plethysmograph, we measured these variables as well as electroencephalography during five conditions: quiet wakefulness, nonrapid-eye-movement sleep, rapid eye movement sleep, and low-dose (60 mg/kg intraperitoneally) and high-dose ketamine anesthesia (125 mg/kg intraperitoneally).

RESULTS

Ketamine anesthesia was associated with markedly increased genioglossus activity (1.5 to fivefold higher values of genioglossus electromyogram) compared with sleep- and propofol-induced unconsciousness. Plethysmography revealed a respiratory stimulating effect: higher values of flow rate, respiratory rate, and duty-cycle (effective inspiratory time, 1.5-to-2-fold higher values). During wakefulness and normal sleep, the δ (f = 6.51, P = 0.04) electroencephalogram power spectrum was an independent predictor of genioglossus activity, indicating an association between electroencephalographic determinants of consciousness and genioglossus activity. Following ketamine administration, electroencephalogram power spectrum and genioglossus electroencephalogram was dissociated (P = 0.9 for the relationship between δ/θ power spectrum and genioglossus electromyogram).

CONCLUSIONS

Ketamine is a respiratory stimulant that abolishes the coupling between loss-of-consciousness and upper airway dilator muscle dysfunction in a wide dose-range. Ketamine compared with propofol might help stabilize airway patency during sedation and anesthesia.

A case of drug rash with eosinophilia and systemic symptoms (DRESS) syndrome complicating airway management

PURPOSE

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a severe multi-system reaction defined by fever, rash, eosinophilia, and internal organ involvement. The condition typically occurs one to eight weeks following exposure to inciting medications. In severe cases, it can develop into multi-organ system failure and death. We present a case of DRESS syndrome with mucosal edema that led to extreme difficulties with airway management.

CLINICAL FEATURES

A 65-yr-old male treated for an esophageal perforation with broad-spectrum antibiotics developed fever, eosinophilia, and extensive rash consistent with DRESS syndrome. This condition resulted in a rapid progression to multi-organ system dysfunction, severe hemodynamic instability, and the need for high-dose vasopressors and tracheal intubation. Extensive mucous membrane involvement led to significant complications with airway management and a nearly impossible tracheal intubation, features in the disease not previously described. With the airway secure, initiation of steroids resulted in regression of the disease within 24 hr, resolution of airway edema, and uneventful tracheal extubation a few days later.

CONCLUSION

We emphasize the need for early identification of DRESS syndrome as well as the possible airway implications associated with this increasingly recognized clinical entity.

A clinical assessment of the Mucus Shaver: a device to keep the endotracheal tube free from secretions

OBJECTIVE

: We evaluated a new device designed to clean the endotracheal tube in mechanically ventilated patients, the Mucus Shaver.

DESIGN

: Prospective, randomized trial.

SETTING

: University hospital intensive care unit.

PATIENTS

: We enrolled 24 patients expected to remain ventilated for >72 hrs.

INTERVENTIONS

: The Mucus Shaver is a concentric inflatable catheter for the removal of mucus and secretions from the interior surface of the endotracheal tube. The Mucus Shaver is advanced to the distal endotracheal tube tip, inflated, and subsequently withdrawn over a period of 3-5 secs. Patients were prospectively randomized within 2 hrs of intubation to receive standard endotracheal tube suctioning treatment or standard suctioning plus Mucus Shaver use until extubation.

MEASUREMENTS AND MAIN RESULTS

: During the study period, demographic data, recent medical history, adverse events, and staff evaluation of the Mucus Shaver were recorded. At extubation, each endotracheal tube was removed, cultured, and analyzed by scanning electron microscopy. Twelve patients were assigned to the study group and 12 were assigned to the control group. No adverse events related to the use of the Mucus Shaver were observed. At extubation, only one endotracheal tube from the Mucus Shaver group was colonized, whereas in the control group ten endotracheal tubes were colonized (8% vs. 83%; p < .001). Scanning electron microscopy showed little secretions on the endotracheal tubes from the study group, whereas thick bacterial deposits were present on all the endotracheal tubes from the control group (p < .001 by Fisher exact test, using a maximum biofilm thickness of 30 μm as cut-off). The nursing staff was satisfied by the overall safety, feasibility, and efficacy of the Mucus Shaver.

CONCLUSIONS

: The Mucus Shaver is a safe, feasible, and efficient device for endotracheal tube cleaning in the clinical setting. The Mucus Shaver is helpful in preventing endotracheal tube colonization by potentially harmful microorganisms.

Negative pressure pulmonary edema following bronchospasm

Negative pressure pulmonary edema (NPPE) is an important cause of noncardiogenic pulmonary edema but is rarely reported in the setting of bronchospasm. A 43-year-old woman with severe reactive airway disease suffered an episode of severe bronchospasm after endotracheal extubation following an otherwise uneventful general anesthetic. Subsequently, she developed clinical and radiographic signs of pulmonary edema in the absence of other symptoms of acute left-sided heart failure, leading to the diagnosis of noncardiogenic pulmonary edema. She received noninvasive positive pressure ventilation for a few hours, after which her clinical and radiologic signs and symptoms of pulmonary edema were greatly improved. This clinical scenario strongly suggests NPPE. We submit that it is possible to create NPPE by generating highly negative intrathoracic pressures in the setting of severe bronchospasm.

Early mobilization in critically ill patients: patients' mobilization level depends on health care provider's profession

OBJECTIVE

To evaluate whether the level of mobilization achieved and the barriers for progressing to the next mobilization level differ between nurses and physical therapists.

DESIGN

Prospective, observational study.

SETTING

Twenty-bed surgical intensive care unit (SICU) of the Massachusetts General Hospital.

PARTICIPANTS

Sixty-three critically ill patients.

METHODS

Physical therapists and nurses performed 179 mobilization therapies with 63 patients.

OUTCOME MEASUREMENT

Mobilization was defined as the process of enhancing mobility in the SICU, including bed mobility, edge of bed activities, transfers out of bed to a chair, and gait training; the mobilization level was measured on the SICU optimal mobilization scale, a 5-point (0-4) numerical rating scale.

RESULTS

Patients' level of mobilization achieved by physical therapists was significantly higher compared with that achieved by nurses (2.3 ± 1.2 mean ± SD versus 1.2 ± 1.2, respectively P < .0001). Different barriers for mobilization were identified by physical therapists and nurses: hemodynamic instability (26% versus 12%, P = .03) and renal replacement therapy (12% versus 1%, P = .03) were barriers rated higher by nurses, whereas neurologic impairment was rated higher by physical therapists providers (18% versus 38%, P = .002). No mobilization-associated adverse events were observed in this study.

CONCLUSIONS

This study showed that physical therapists mobilize their critically ill patients to higher levels compared with nurses. Nurse and physical therapists identify different barriers for mobilization. Routine involvement of physical therapists in directing mobilization treatment may promote early mobilization of critically ill patients.