Core competency in mechanical ventilation: development of educational objectives using the Delphi technique.

OBJECTIVES: We sought to identify and standardize the core clinical knowledge and skills required to care for patients receiving mechanical ventilation. DESIGN: Prospective survey reaching consensus by the Delphi technique. SETTING: North American survey conducted anonymously by electronic e-mail. SUBJECTS: International experts in mechanical ventilation, frontline resident educators, medical education experts, and community intensivists were recruited to participate MEASUREMENTS AND MAIN RESULTS: Fourteen panelists participated (ten content experts, three resident educators, one medical education expert, zero community intensivists). Individual panelists generated a total of 200 educational objectives, of which 109 were duplicates. Of the remaining 91 items, 56 met predefined consensus criteria for inclusion in the final set of educational objectives. The educational objectives spanned a broad range of categories, including respiratory physiology, noninvasive ventilation, lung protective ventilation, weaning, and withholding and withdrawing mechanical ventilation. Agreement among panelists on the items included was high (median proportion supporting item inclusion was 88%, range 70%-100%). CONCLUSIONS: There is a consensus that general resident core competency in mechanical ventilation requires a broad range of knowledge application and skill. These educational objectives may help identify and standardize the educational outcomes related to mechanical ventilation that residents should achieve.

Guidelines for the withdrawal of life-sustaining measures.

BACKGROUND: Withdrawal of life-sustaining measures is a common event in the intensive care unit yet it involves a complex balance of medical, legal and ethical considerations. Very few healthcare providers have been specifically trained to withdraw life-sustaining measures, and no comprehensive guidelines exist to help ensure clinicians deliver the highest quality of care to patients and families. Hence, we sought to develop guidelines for the process of withdrawing life-sustaining measures in the clinical setting. METHODS: We convened an interdisciplinary group of ICU care providers from the Canadian Critical Care Society and the Canadian Association of Critical Care Nurses, and used a modified Delphi process to answer key clinical and ethical questions identified in the literature. RESULTS: A total of 39 experienced clinicians completed the initial workshop, and 36 were involved in the subsequent Delphi rounds. The group developed a series of guidelines to address (1) preparing for withdrawal of life-sustaining measures; (2) assessment of distress; (3) pharmaceutical management of distress; and (4) discontinuation of life-sustaining measures and monitoring. The group achieved consensus on all aspects of the guidelines after the third Delphi round. CONCLUSION: We present these guidelines to help physicians provide high-quality end of life (EOL) care in the ICU. Future studies should address their effectiveness from both critical care team and family perspectives.

Ventilator settings and monitoring parameter targets for initiation of continuous mandatory ventilation: a questionnaire study.

PURPOSE: To inform development of educational tools, we sought to identify initial ventilator settings and monitoring targets for 3 scenarios. METHOD: A survey was e-mailed to Canadian Society of Respiratory Therapists members with 2 reminders in March/April 2011. RESULTS: Total evaluable surveys were 363. More participants selected pressure as opposed to volume ventilation for acute respiratory distress syndrome (ARDS; 77%) than for chronic obstructive pulmonary disease (COPD; 50%) and postoperative ventilation (32%; P < .001). Mean tidal volume was lower for ARDS than for COPD and postoperative ventilation (5.7, 6.9, and 7.2 mL/kg, respectively; P < .001). Maximum acceptable plateau pressures were highest for ARDS (30 cm H2O vs 29 cm H2O [COPD] and 27 cm H2O [postoperative], P < .001). Initial positive expiratory end pressure (12 cm H2O vs 7 cm H2O vs 5 cm H2O) and fraction of inspired oxygen (Fio2; 1.0 vs 0.5 vs 0.3) were also higher for ARDS (both P < .001); however, only 8% selected a positive expiratory end pressure/Fio2 combination as recommended by ARDSnet. Values of oxygen saturation as measured by pulse oximetry of 97% (ARDS) and 94% (COPD and postoperative) were considered appropriate for Fio2 reduction. The lowest pH was 7.28 vs 7.23 vs 7.26; the highest pH was 7.46 vs 7.44 vs 7.46 (P < .001). Partial pressure of carbon dioxide (arterial) of 51 mm Hg (postoperative) to 65 mm Hg (ARDS) was considered acceptable. CONCLUSION: Lung protective ventilation was favored, yet distinct differences in ventilator settings were evident. Monitoring targets suggested relatively conservative practices for Fio2 reduction but an understanding of permissive hypercapnia.

Advantages and disadvantages of etomidate use for intubation of patients with sepsis.

Etomidate is a potent imidazole hypnotic used widely in single doses in the rapid sequence intubation of critically ill patients with sepsis due to its presumed hemodynamic safety, fast onset, and short duration of action. However, the literature is conflicting regarding the hemodynamic advantages of etomidate over other induction agents, and its safety in this population is a matter of strong debate in the critical care community as the drug is associated with suppression of adrenal steroidogenesis, which can last up to 72 hours after a single dose, primarily through potent inhibition of the 11ß-hydroxylase enzyme. However, the clinical impact of this adrenal suppressive effect is not certain. The use of continuous-infusion etomidate in critically ill patients was abandoned more than 20 years ago due to reports of increased mortality. Nevertheless, mortality data of single-dose etomidate are still controversial, with no strong evidence of benefit over other agents and a tendency toward harm (keeping in mind the limitations of the available literature). Proponents of single-dose etomidate use in patients with sepsis suggest that the increased mortality associated with etomidate is merely a reflection of the patients' severity of illness and not related to the drug itself, whereas others believe that the drug causes true harm and increases mortality in this population. In view of the lack of a clear clinical advantage of etomidate over other agents used in rapid sequence intubation, it would be prudent to favor other agents until further conclusive evidence of etomidate safety is available in critically ill patients with sepsis.

Educating providers of mechanical ventilation: an update.

PURPOSE OF REVIEW: In recent years, research has led to changes in the practice of mechanical ventilation that are associated with improved patient outcome. Unfortunately, many of these recommendations have not been consistently translated to the bedside. Education is an important component of change management, and thus a review of successful education practices, including those that incorporate advances in technology, is timely. RECENT FINDINGS: We are failing to adequately teach important concepts in mechanical ventilation to those healthcare providers in training and to those currently in practice. There are few explicit links between phases of training that ensure achievement of learning objectives related to mechanical ventilation. Targeted multifaceted education initiatives, however, have been shown to reduce the incidence of suboptimal mechanical ventilation care. Advances in simulation technology (table-top simulators, personal computer-based simulators, and high-fidelity patient simulators) have created new educational tools, although it has not been demonstrated how to effectively integrate ventilation simulation into a curriculum map. SUMMARY: A coordinated approach to education about mechanical ventilation should be considered to ensure optimal patient care in a wide variety of clinical settings. Further research is necessary to determine the important characteristics inherent in successful education initiatives, particularly those incorporating new technology such as simulation.