Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system. CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Executive Summary: Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU.

RATIONALE: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients. OBJECTIVES: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients. PANEL DESIGN: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines. METHODS: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs). RESULTS: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS). CONCLUSIONS: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU.

Interfacility Transport of Critically Ill Patients.

OBJECTIVES: To assess recent advances in interfacility critical care transport. DATA SOURCES: PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION: Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION: Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS: The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS: Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Personal protective equipment (PPE) for both anesthesiologists and other airway managers: principles and practice during the COVID-19 pandemic.

Healthcare providers are facing a coronavirus disease pandemic. This pandemic may last for many months, stressing the Canadian healthcare system in a way that has not previously been seen. Keeping healthcare providers safe, healthy, and available to work throughout this pandemic is critical. The consistent use of appropriate personal protective equipment (PPE) will help assure its availability and healthcare provider safety. The purpose of this communique is to give both anesthesiologists and other front-line healthcare providers a framework from which to understand the principles and practices surrounding PPE decision-making. We propose three types of PPE including: 1) PPE for droplet and contact precautions, 2) PPE for general airborne, droplet, and contact precautions, and 3) PPE for those performing or assisting with high-risk aerosol-generating medical procedures.

RéSUMé: Les professionnels de la santé sont confrontés à une pandémie de coronavirus 2019 (COVID-19). Cette pandémie pourrait durer plusieurs mois, soumettant le système de santé canadien à des pressions jusqu'alors méconnues. Il est essentiel de garder les professionnels de la santé en sécurité, en santé et disponibles tout au long de cette pandémie. Une utilisation cohérente des équipements de protection individuelle (EPI) adaptés nous aidera à garantir leur disponibilité et la sécurité des professionnels de la santé. L'objectif de ce communiqué est de fournir aux anesthésiologistes et aux autres professionnels de la santé de première ligne un cadre leur permettant de comprendre les principes et les pratiques entourant la prise de décision par rapport aux EPI. Nous proposons trois types d'EPI, soit 1) les EPI pour prendre des précautions contre les gouttelettes et le contact; 2) les EPI pour prendre des précautions générales contre les suspensions aériennes, les gouttelettes et le contact; et 3) les EPI pour les professionnels réalisant ou assistant des interventions médicales à haut risque de génération d'aérosols.

Just the Facts: Protected code blue - Cardiopulmonary resuscitation in the emergency department during the coronavirus disease 2019 pandemic.

Emergency medical services (EMS) is called for a 65-year-old man with a 1-week history of cough, fever, and mild shortness of breath now reporting chest pain. Vitals on scene were HR 110, BP 135/90, SpO2 88% on room air. EMS arrives at the emergency department (ED). As the patient is moved to a negative pressure room, he becomes unresponsive with no palpable pulse. What next steps should be discussed in order to protect the team and achieve the best possible patient outcome?

Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients.

A global health emergency has been declared by the World Health Organization as the 2019-nCoV outbreak spreads across the world, with confirmed patients in Canada. Patients infected with 2019-nCoV are at risk for developing respiratory failure and requiring admission to critical care units. While providing optimal treatment for these patients, careful execution of infection control measures is necessary to prevent nosocomial transmission to other patients and to healthcare workers providing care. Although the exact mechanisms of transmission are currently unclear, human-to-human transmission can occur, and the risk of airborne spread during aerosol-generating medical procedures remains a concern in specific circumstances. This paper summarizes important considerations regarding patient screening, environmental controls, personal protective equipment, resuscitation measures (including intubation), and critical care unit operations planning as we prepare for the possibility of new imported cases or local outbreaks of 2019-nCoV. Although understanding of the 2019-nCoV virus is evolving, lessons learned from prior infectious disease challenges such as Severe Acute Respiratory Syndrome will hopefully improve our state of readiness regardless of the number of cases we eventually manage in Canada.

RéSUMé: Une urgence sanitaire mondiale a été déclarée par l'Organisation mondiale de la Santé alors que l'épidémie de 2019-nCoV se répand dans le monde et que des cas ont été confirmés au Canada. Les patients infectés par le 2019-nCoV sont à risque d'insuffisance respiratoire et peuvent nécessiter une admission à l'unité de soins intensifs. Lors d'une prise en charge optimale de ces patients, il est indispensable de prendre soin d'exécuter rigoureusement les mesures de contrôle des infections afin de prévenir la transmission nosocomiale aux autres patients et aux travailleurs de la santé prodiguant les soins. Bien que les mécanismes précis de transmission ne soient pas encore connus, la transmission d'humain à humain peut survenir, et le risque de dissémination aérienne pendant les interventions médicales générant des aérosols est préoccupant dans certaines circonstances spécifiques. Cet article résume des considérations importantes en ce qui touche au dépistage des patients, aux contrôles environnementaux, au matériel de protection personnelle, aux mesures de réanimation (y compris l'intubation), et à la planification des activités à l'unité de soins intensifs alors que nous nous préparons à la possibilité de nouveaux cas importés ou d'éclosions locales du 2019-nCoV. Bien que la compréhension du virus 2019-nCoV continue d'évoluer, nous espérons que les leçons retenues des éclosions précédentes de maladies infectieuses telles que le syndrome respiratoire aigu sévère nous permettront d'améliorer notre degré de préparation, indépendamment du nombre de cas que nous traiterons au Canada.

Preparing the Intensive Care Unit for Disaster.

Critical care teams can face a dramatic surge in demand for ICU beds and organ support during a disaster. Through effective preparedness, teams can enable a more effective response and hasten recovery back to normal operations. Disaster preparedness needs to balance an all-hazards approach with focused hazard-specific preparation guided by a critical care-specific hazard-vulnerability analysis. Broad stakeholder input from within and outside the critical care team is necessary to avoid gaps in planning. Evaluation of critical care disaster plans require frequent exercises, with a mechanism in place to ensure lessons learned effectively prompt improvements in the plan.

Improving use of targeted temperature management after out-of-hospital cardiac arrest: a stepped wedge cluster randomized controlled trial.

RATIONALE: International guidelines recommend use of targeted temperature management following resuscitation from out-of-hospital cardiac arrest. This treatment, however, is often neglected or delayed. OBJECTIVE: To determine whether multifaceted quality improvement interventions would increase the proportion of eligible patients receiving successful targeted temperature management. SETTING: A network of 6 regional emergency medical services systems and 32 academic and community hospitals serving a population of 8.8 million people providing post arrest care to out-of-hospital cardiac arrest. INTERVENTIONS: Comparing interventions improve the implementation of targeted temperature management post out-of-hospital cardiac arrest through passive (education, generic protocol, order set, local champions) versus additional active quality improvement interventions (nurse specialist providing site-specific interventions, monthly audit-feedback, network educational events, internet blog) versus no intervention (baseline standard of care). MEASUREMENTS AND MAIN RESULTS: The primary process outcome was proportion of eligible patients receiving successful targeted temperature management, defined as a target temperature of 32-34ºC within 6 hours of emergency department arrival. Secondary clinical outcomes included survival and neurological outcome at hospital discharge. Four thousand three hundred seventeen out-of-hospital cardiac arrests were transported to hospital; 1,737 (40%) achieved spontaneous circulation, and 934 (22%) were eligible for targeted temperature management. After accounting for secular trends, patients admitted during the passive quality improvement phase were more likely to achieve successful targeted temperature management compared with those admitted during the baseline period (25.7% passive vs 9.0% baseline; odds ratio, 2.76; 95% CI, 1.76-4.32; p < 0.001). Active quality improvement interventions conferred no additional improvements in rates of successful targeted temperature management (26.9% active vs 25.7% passive; odds ratio, 0.96; 95% CI, 0.63-1.45; p = 0.84). Despite a significant increase in rates of successful targeted temperature management, survival to hospital discharge was unchanged. CONCLUSION: Simple quality improvement interventions significantly increased the rates of achieving successful targeted temperature management following out-of-hospital cardiac arrest in a large network of hospitals but did not improve clinical outcomes.

Effectiveness of using high-fidelity simulation to teach the management of general anesthesia for Cesarean delivery.

PURPOSE: The objective of this study was to assess the influence of a teaching plan consisting of didactic teaching and repeated simulations on the performance of anesthesia residents in the management of general anesthesia (GA) for emergency Cesarean delivery (CD). METHODS: Twenty-one postgraduate year 2 (PGY2) and 3 (PGY3) anesthesia residents from the University of Toronto were recruited in this prospective cohort study. All participants received didactic teaching in the management of GA for emergency CD, which was followed one week later by assessment of performance in the same scenario using a high-fidelity simulator. Another simulation assessment was repeated two months later in the same scenario. All simulation video recordings were assessed by two blinded experts using a validated checklist and an Anaesthetists' Non-Technical Skills (ANTS) scale in order to rate their technical and non-technical skills, respectively. The participants' performance (based on the above scales) in the two simulation sessions were then compared. RESULTS: Nineteen residents completed both simulation sessions. There was an improvement in the mean (SD) weighted checklist score from 64.5% (7.1%) in session 1 to 76.7% (6.7%) in session 2 (P < 0.001). The mean (SD) ANTS scores also increased from 2.8 (0.5) in session 1 to 3.3 (0.4) in session 2 (P = 0.001). No difference in the checklist or ANTS scores was seen between PGY2 and PGY3 residents in any of the simulation sessions. Several common performance errors were identified, but these improved in the second session. The correlation between checklist and ANTS scores was moderately high (correlation coefficient [r] = 0.7; P < 0.001). The inter-rater reliability among the experts was also high (intraclass correlation coefficient [ICC] for the checklist = 0.72; 95% confidence interval [CI] 0.62 to 0.81; ICC for the ANTS = 0.74; 95% CI 0.49 to 0.89). CONCLUSION: Didactic teaching followed by simulation sessions enhances not only the technical skills but also the non-technical skills of residents, most likely due to the feedback received after the first simulation session. Repeated simulation sessions may help prepare residents to deal more effectively with similar critical situations in clinical practice with minimum errors.

An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients.

INTRODUCTION: Increasing antimicrobial costs, reduced development of novel antimicrobials, and growing antimicrobial resistance necessitate judicious use of available agents. Antimicrobial stewardship programs (ASPs) may improve antimicrobial use in intensive care units (ICUs). Our objective was to determine whether the introduction of an ASP in an ICU altered the decision to treat cultures from sterile sites compared with nonsterile sites (which may represent colonization or contamination). We also sought to determine whether ASP education improved documentation of antimicrobial use, including an explicit statement of antimicrobial regimen, indication, duration, and de-escalation. METHODS: We retrospectively analyzed consecutive patients with positive bacterial cultures admitted to a 16-bed medical-surgical ICU over 2-month periods before and after ASP introduction (April through May 2008 and 2009, respectively). We evaluated the antimicrobial treatment of positive sterile- versus nonsterile-site cultures, specified a priori. We reviewed patient charts for clinician documentation of three specific details regarding antimicrobials: an explicit statement of antimicrobial regimen/indication, duration, and de-escalation. We also analyzed cost and defined daily doses (DDDs) (a World Health Organization (WHO) standardized metric of use) before and after ASP. RESULTS: Patient demographic data between the pre-ASP (n = 139) and post-ASP (n = 130) periods were similar. No difference was found in the percentage of positive cultures from sterile sites between the pre-ASP period and post-ASP period (44.9% versus 40.2%; P = 0.401). A significant increase was noted in the treatment of sterile-site cultures after ASP (64% versus 83%; P = 0.01) and a reduction in the treatment of nonsterile-site cultures (71% versus 46%; P = 0.0002). These differences were statistically significant when treatment decisions were analyzed both at an individual patient level and at an individual culture level. Increased explicit antimicrobial regimen documentation was observed after ASP (26% versus 71%; P < 0.0001). Also observed were increases in formally documented stop dates (53% versus 71%; P < 0.0001), regimen de-escalation (15% versus 23%; P = 0.026), and an overall reduction in cost and mean DDDs after ASP implementation. CONCLUSIONS: Introduction of an ASP in the ICU was associated with improved microbiologically targeted therapy based on sterile or nonsterile cultures and improved documentation of antimicrobial use in the medical record.

A retrospective cohort pilot study to evaluate a triage tool for use in a pandemic.

INTRODUCTION: The objective of this pilot study was to assess the usability of the draft Ontario triage protocol, to estimate its potential impact on patient outcomes, and ability to increase resource availability based on a retrospective cohort of critically ill patients cared for during a non-pandemic period. METHODS: Triage officers applied the protocol prospectively to 2 retrospective cohorts of patients admitted to 2 academic medical/surgical ICUs during an 8 week period of peak occupancy. Each patient was assigned a treatment priority (red -- 'highest', yellow -- 'intermediate', green -- 'discharge to ward', or blue/black -- 'expectant') by the triage officers at 3 separate time points (at the time of admission to the ICU, 48, and 120 hours post admission). RESULTS: Overall, triage officers were either confident or very confident in 68.4% of their scores; arbitration was required in 54.9% of cases. Application of the triage protocol would potentially decrease the number of required ventilator days by 49.3% (568 days) and decrease the total ICU days by 52.6% (895 days). On the triage protocol at ICU admission the survival rate in the red (93.7%) and yellow (62.5%) categories were significantly higher then that of the blue category (24.6%) with associated P values of < 0.0001 and 0.0003 respectively. Further, the survival rate of the red group was significantly higher than the overall survival rate of 70.9% observed in the cohort (P < 0.0001). At 48 and 120 hours, survival rates in the blue group increased but remained lower then the red or yellow groups. CONCLUSIONS: Refinement of the triage protocol and implementation is required prior to future study, including improved training of triage officers, and protocol modification to minimize the exclusion from critical care of patients who may in fact benefit. However, our results suggest that the triage protocol can help to direct resources to patients who are most likely to benefit, and help to decrease the demands on critical care resources, thereby making available more resources to treat other critically ill patients.

Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents.

OBJECTIVE: We aimed to determine internal medicine residents' perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal. DESIGN: Cross-sectional postal survey. SETTING: Canadian internal medicine training programs. PARTICIPANTS: Internal medicine residents attending Canadian English-speaking medical schools. INTERVENTIONS: A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools. MEASUREMENTS AND MAIN RESULTS: Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r(2) = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence. CONCLUSIONS: The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.

Development of a triage protocol for critical care during an influenza pandemic.

BACKGROUND: The recent outbreaks of avian influenza (H5N1) have placed a renewed emphasis on preparing for an influenza pandemic in humans. Of particular concern in this planning is the allocation of resources, such as ventilators and antiviral medications, which will likely become scarce during a pandemic. METHODS: We applied a collaborative process using best evidence, expert panels, stakeholder consultations and ethical principles to develop a triage protocol for prioritizing access to critical care resources, including mechanical ventilation, during a pandemic. RESULTS: The triage protocol uses the Sequential Organ Failure Assessment score and has 4 main components: inclusion criteria, exclusion criteria, minimum qualifications for survival and a prioritization tool. INTERPRETATION: This protocol is intended to provide guidance for making triage decisions during the initial days to weeks of an influenza pandemic if the critical care system becomes overwhelmed. Although we designed this protocol for use during an influenza pandemic, the triage protocol would apply to patients both with and without influenza, since all patients must share a single pool of critical care resources.

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.

Outcomes of interfacility critical care adult patient transport: a systematic review.

INTRODUCTION: We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients. METHODS: We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined. RESULTS: Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies. CONCLUSION: Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.

Can 1 microg of cosyntropin be used to evaluate adrenal insufficiency in critically ill patients?

OBJECTIVE: To evaluate the utility of cosyntropin 1 microg in assessing adrenal function in critically ill patients. DATA SOURCES: A computerized literature search using MEDLINE, EMBASE, International Pharmaceutical Abstracts, and the Cochrane Database (1966-August 2004) was undertaken for trials evaluating cosyntropin 1 mug using the following search terms: adrenocorticotropin-releasing hormone (ACTH), cosyntropin, adrenal insufficiency, cortisol, corticosteroids, glucocorticoids, sepsis, septic shock, diagnosis, critically ill, intensive care, and critical care. STUDY SELECTION AND DATA SYNTHESIS: Identifying patients with sepsis with relative adrenal insufficiency (AI) using cosyntropin testing may identify those likely to benefit from corticosteroids. The results of 5 heterogeneous studies in non-intensive care unit (ICU) patients suggest that both 1 microg and 250 microg of cosyntropin stimulate similar cortisol responses and that testing using both doses correlates well with results from insulin tolerance testing. Some data from non-ICU patients suggest that the 1-microg test may be more sensitive to detect AI; 3 heterogeneous studies in ICU patients confirmed the improved sensitivity of the 1-microg test. CONCLUSIONS: Use of cosyntropin 1 microg should detect AI in all patients who would have been diagnosed using 250 microg. Unfortunately, all of the clinical trials evaluating the role of corticosteroids in septic shock that used the cosyntropin stimulation test administered 250 microg. Extrapolation of the existing guidelines to treat patients with septic shock testing positive for relative AI using the 1-microg test may provide effective therapy to appropriate patients not diagnosed by the 250-microg testing or may introduce additional adverse effects in patients who should not receive corticosteroids. Large-scale, head-to-head comparison data of steroid effectiveness after 1- and 250-microg ACTH stimulation tests are needed to expand upon these promising results.