Critical Care Clinics

Knowledge of the airway is expanding. New conditions, modern management strategies, and a more complete understanding of the interaction between the airway and fluid flux in the lung are presented.

The creation of a partnership, the hallmark of true collaborative practice, is an ongoing, dynamic process. It demands commitment, energy, and creativity. It is learned and therefore must be role modeled. One must remember that it takes time to develop collaborative relationships. One must begin slowly, walk not run, and have realistic expectations. It is a joy to work in an environment that has developed and is in the process of continually developing true collaborative practice. Hope for the future of health care lies in our ability to deliver coordinated and collaborative care. Nursing, medicine, and administration together can and must provide the solutions to our health care delivery problems before those solutions are legislated. We must set policies and priorities to appropriately allocate scarce resources. We must address personnel needs, credentialing, and compensation to ensure adequate numbers of qualified staff to meet the growing needs of our patients. We must evaluate technology and our physical environments to determine the types of services that we will offer. We must continue to broaden our collaborative efforts to extend from the patient care arena into the realms of education, research, and administration. It is up to each of us and each of our colleagues to work every day toward a more collaborative practice environment. By empowering each other, we can put into place a collaboration which "works jointly with others in intellectual endeavors" rather than one which merely "cooperates with an enemy force."

The evidence supports quality controlled chest compression as the initial intervention after "sudden death" before attempted defibrillation, if the duration of cardiac arrest is more than 5 minutes. The new guidelines mandate lesser interruptions for ventilation, before and following electrical shocks, and single rather than multiple electrical shocks before resuming chest compression. The new guidelines refocus on uninterrupted chest compression after cardiac arrest of nonasphyxial cause and modifications in practices that reduce the need for interruptions.

This article discusses current efforts to develop hemoglobin-based oxygen carriers as blood substitutes in light of the worldwide shortage of safe and viable allogeneic donor blood. There are now viable approaches to modify the intrinsic biologic properties of hemoglobin to produce improved hemoglobin-based oxygen carriers. Polymerized hemoglobin preparations have proved most successful in clinical trials due to their improved side effect profile. The goal is to evaluate blood substitutes with enhanced intravascular retention, reduced osmotic activity, and attenuated hemodynamic derangements such as vasoconstriction. Although not without substantial morbidity and mortality, the current safety of allogeneic blood transfusion demands that comparative studies show minimal adverse effects as well as efficacy and potential for novel applications.

Traumatic brain injury (TBI) remains the leading cause of death of children in the developing world. In 2012, several international efforts were completed to aid clinicians and researchers in advancing the field of pediatric TBI. The second edition of the Guidelines for the Medical Management of Traumatic Brain Injury in Infants, Children and Adolescents updated those published in 2003. This article highlights the processes involved in developing the Guidelines, contrasts the new guidelines with the previous edition, and delineates new research efforts needed to advance knowledge. The impact of common data elements within these potential new research fields is reviewed.

This article reviews important literature on the FAST and E-FAST examinations in adults. It also reviews key pitfalls, limitations, and controversies. A practical "how-to" guide is presented. Lastly, new frontiers are explored.

This article reviews the hypothesis that staffing with full-time intensive care physicians leads to improvements in the management of ICUs and in the outcome for ICU patients. Variations in the professional organization of critical care units in the United States are discussed. The advantages and disadvantages of open, closed, and transitional (comanagement) ICU organizational structures are presented.

Over the last 20 years, hands-only cardiopulmonary resuscitation (CPR) has been investigated as an alternative to conventional CPR with rescue breathing for sudden cardiac arrest. Studies suggest that hands-only CPR is at least as effective as conventional CPR for bystander out-of-hospital cardiac arrest. Despite the value of hands-only CPR, it is less effective and should be avoided with a prolonged bystander CPR period or cardiac arrest of noncardiac origin, typically asphyxial. Because pediatric cardiac arrests and adult in-hospital cardiac arrests are most commonly caused by asphyxia, conventional CPR with assisted ventilation should be provided in these settings.

The following six points offer a summary of principles to the manager who must develop a QA program: Institutional commitment to the QA process is essential for success. This must be embodied in the table of organization for QA and the commitment of resources to the task. The QA plan should address mechanisms for data collection, data review, and outcome reporting. Lines of responsibility should be stated clearly. The manner in which the outcomes of the QA process are implemented and communicated back to the front-line workers must be clearly stated and continually fed back to them. Clinical evaluations work best in the presence of politically neutral practice guidelines. Vociferous complainers frequently can be made part of the process, harnessing their energy to good effect. Self survey should precede an accreditation site visit by at least 6 months. The best sources of JCAHO thinking on QA methods are the many JCAHO publications, several of which focus on the critical care arena.

Among patients with life-threatening sepsis that has no clear site of origin, the abdomen continues to be a probable and tractable possibility. The cavity has the microbiologic and anatomic potential for sudden or indolent sepsis and the cause may be either obvious or obscure. The abdomen or the various structures may be primary sources that are secondary and independent of disease that brought the patient to peril. They also could be secondary and dependent upon an abdominal operation complicated by sepsis. The partnership of intensivist and surgical consultant, addressing possibilities and challenges, must identify the most probable cause and the most timely response for positive intervention in the critically ill patient threatened by sepsis.

The plain film of the abdomen usually is the first radiographic examination ordered to evaluate the abdomen in the ICU patient. It is inexpensive, universally available and may be done at the bedside in the ICU. This article details and describes what to look for when interpreting a plain radiograph of the abdomen.

In one's attempt to arrive at the most accurate diagnosis in the critically ill, the selection of the most efficacious and rapid imaging modality can be problematic to clinicians, especially if the clinical presentation is confusing. The selection most often, is between US and CT. In general, US is advantageous in that it can be performed at bedside and is a faster and less costly examination. Its main disadvantages are interference from intestinal gaseous distention, restricted field of view from surgical dressings or wounds, and operator-dependence for accuracy. With the newer and faster CT scanners, CT is gaining an increasingly important role in the evaluation of the critically ill, despite the need for patient transport to the radiology department. It is more effective in displaying and localizing abnormalities and more helpful for drainage guidance than US. The potential benefit of CT should outweight the risk of transport of the unstable patient, and because of CT's high cost, appropriate timing of the study and expected diagnostic benefit should be taken into consideration. Norwood reported that CT was not positive for abscess prior to the eighth postoperative day, only 55% of examinations aided in or altered the pre-examination diagnosis, and more than 70% were of no benefit to the patient. An organized approach is essential in solving complex diagnostic problems if one is to enhance patient care and efficacious use of personnel and resources. This can be accomplished best by direct communication between clinicians and radiologists before and after the examination. Radiologists who understand the clinical problems and are familiar with all diagnostic modalities should be consulted for the selection of the modality best suited to answering the question at hand. Similarly, critically ill patients should benefit most if clinicians and radiologists review the examination results together in light of the clinical presentation for more accurate and meaningful diagnosis.

In summary, ultrasonography and its recent advances appear ideally suited to a number of conditions common in the critically ill patient and the ICU setting. Depending on the clinical situation, and, providing appropriate technical expertise is available, ultrasonography can both gather diagnostic information and, where indicated, guide therapeutic intervention.

Abdominal pathology in the critically ill or injured patient frequently leads to the use of open abdominal techniques or the actual performance of abdominal surgery in the ICU. All individuals responsible for the care of patients in the ICU should be familiar with the concepts and techniques of open abdomen wound management. ICU bedside abdominal surgery may be indicated if the patient is too unstable for transport to the operating room and the surgeon believes a limited procedure, such as a decompression of IAH, will be life-saving. Smaller procedures are also feasible, such as intra-abdominal packing changes for which the operating room is unnecessary. Development of a successful Surgery Outside the Operating Room program depends on mature cooperation between the surgeons and other professional ICU staff. Logistic details of such a program should be discussed and a scheduling protocol should be prepared before an emergent need for bedside surgery.

Patients in the setting of the intensive care unit can develop intra-abdominal complications that may worsen outcome. Clinical suspicion of such complications coupled with early diagnosis and treatment may reduce morbidity and mortality associated with these processes. This article addresses the diagnosis and management of some of the common causes of intra-abdominal catastrophes.

During the past 15 years, many different studies have documented improved blood pressure and blood flow above the diaphragm when some type of abdominal compression was added to conventional CPR, either in animals or in humans. Rhythmically interposed abdominal compressions seem to provide even greater hemodynamic benefit than continuous abdominal binding. Both total flow and the distribution of flow to vital organs above the diaphragm are improved, while the chances of liver entrapment and damage during chest compression are reduced. The technique of interposed abdominal compression can be performed with the bare hands of a second or third rescuer. It requires no special equipment, and could be easily incorporated into existing training programs for basic rescuers. In this sense the technique may constitute a logical evolution in basic life support, if subsequent clinical research confirms that it improves outcome.

Trauma is the leading cause of death between the ages of 1 and 44 years. In all age groups, it is surpassed only by cancer and atherosclerosis in mortality [1]. The evaluation and treatment of abdominal injuries are critical components in the management of severely injured trauma patients. Because missed intra-abdominal injuries are a frequent cause of preventable trauma deaths, a high index of suspicion is warranted. Multiple factors, including the mechanism of injury, the body region injured, the patient's hemodynamic and neurologic status, associated injuries, and institutional resources influence the diagnostic approach and the outcome of abdominal injures.

Markedly elevated intra-abdominal pressures will result in predictable hemodynamic consequences related to compromised venous return. When the hemodynamic abnormalities are associated with organ dysfunction of failure, patients suffer from the abdominal compartment syndrome. At-risk patients should be routinely monitored for intra-abdominal hypertension, and a multidisciplinary care paradigm should be established. Vigorous resuscitation of both surgical and medical patients highly correlates with IAH and ACS risk. Vigilance, prompt diagnosis, and intervention for abdominal compartment syndrome will reduce the morbidity and mortality in critically ill. Future challenges include altering resuscitation strategies to reduce ascites formation, earlier diagnosis of organ dysfunction, and intra-organ monitoring techniques.

Cancer patients are at risk for profound derangements in the hemostatic mechanism due to multiple factors. Depending upon the dominant abnormality, bleeding, thrombosis or both, in conjunction with disseminated intravascular coagulation, may occur. Critical care physicians should have a high index of suspicion for underlying hemostatitic defects when a cancer patient presents with hemorrhage. Blood replacement therapy tailored to specific abnormalities coupled with effective treatment of the underlying malignancy will render the best result. Thrombosis in malignancy is a frequent occurrence and increasing in incidence due in part to the widespread use of indwelling venous catheters. Fibrinolytic therapy is effective and probably under-utilized in treating thrombosis but must be approached with care in these patients. A thorough understanding of diagnostic techniques, indications, and potential complications of anticoagulant therapy in cancer patients is essential.

Systemic acidosis has a negative inotropic effect on myocardial function, which in the intact animal, is counteracted by the activation of the sympathoadrenal system. Although there are extensive animal data in this field, human studies quantifying the influence of systemic acidosis on myocardial function in various disease states is lacking. In patients with hypocalcemia, a single infusion of calcium does not sustain increased calcium levels, and the hemodynamic improvement is only transient. Hemodynamic changes in septic shock are complex, and there are convincing data documenting myocardial dysfunction in sepsis. There is a need for elucidating the biochemical characteristics of the myocardial depressant factor (or factors).

Patients with cancer are at risk for developing a variety of fluid and electrolyte disturbances caused by the disease process or by complications from therapy. An understanding of the pathophysiology of these potential abnormalities allows the clinician to manage patients expectantly and to avoid severe metabolic disarray by correcting imbalances promptly.

CINMAs occur commonly in acutely critically ill inflamed patients, and can prolong respiratory failure, lead to ventilator dependency, and contribute to the development of chronic critical illness. The etiology of NMDs are diverse and overlap, and distinguishing different disease entities by clinical exam and electrophysiologic studies can be difficult. CIP, which has been the most widely studied CINMA, represents the peripheral nervous system manifestation of the MODS. Patients with CIP, particularly those with severely reduced nerve function, have a prolonged rehabilitation and a high mortality rate. Although there are no definitive treatments, diagnosing a CINMA may provide helpful prognostic information. Future preventative measures may include immunoglobulin, nerve growth factors, or strict glycemic control, although in the CCI phase general supportive care is given, including prevention of iatrogenic complications, nutritional support, psychosocial support, and physical therapy. The early recognition of CINMAs and prevention of associated complications are important to enabling CCI patients with CINMAs to recover and return home with an acceptable functional level and quality of life.

This article reviews the life-threatening fluid and electrolyte abnormalities that develop in association with, or as a result of neoplasms or their therapy. Ectopic hormone secretion by tumors and their resultant electrolyte aberrancies are also discussed. The emphasis of this article is on clinical phenomena encountered in the ICU that are specific to cancers and their therapy rather than being a review of electrolyte abnormalities in general. Each topic includes a discussion of the management of the abnormality.

Despite our heightened awareness of placental abruption, this condition remains largely unpreventable. The incidence of placental abruption may actually be on the rise due to increasing use of cocaine and "crack" and a greater contribution from abdominal trauma. Whether recurrence of abruption associated with hypertension can be prevented with low-dose aspirin is yet to be determined. Unfortunately, although our recognition of this condition may have improved, placental abruption remains a high cause of perinatal morbidity and mortality.

Substance use is common among individuals admitted to the critical care setting and may complicate treatment of underlying disorders. It is imperative for the critical care team to have a high index of suspicion for substance intoxication and withdrawal. This article reviews the epidemiology of substance use in this population and the treatment of common withdrawal syndromes. General principles regarding the management of substance withdrawal syndromes include general resuscitative measures, use of a symptom-triggered approach, and substitution of a long-acting replacement for the abused drug in gradual tapering dose. The authors stress the importance of long-term planning as part of the overall treatment protocol beyond the acute presentation.