Operative management of rib fractures in the setting of flail chest: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis of studies comparing operative to nonoperative therapy in adult FC patients. Outcomes were duration of mechanical ventilation (DMV), intensive care unit length of stay (ICULOS), hospital length of stay (HLOS), mortality, incidence of pneumonia, and tracheostomy. BACKGROUND: Flail chest (FC) results in paradoxical chest wall movement, altered respiratory mechanics, and frequent respiratory failure. Despite advances in ventilatory management, FC remains associated with significant morbidity and mortality. Operative fixation of the flail segment has been advocated as an adjunct to supportive care, but no definitive clinical trial exists to delineate the role of surgery. METHODS: A comprehensive search of 5 electronic databases was performed to identify randomized controlled trials and observational studies (cohort or case-control). Pooled effect size (ES) or relative risk (RR) was calculated using a fixed or random effects model, as appropriate. RESULTS: Nine studies with a total of 538 patients met inclusion criteria. Compared with control treatment, operative management of FC was associated with shorter DMV [pooled ES: -4.52 days; 95% confidence interval (CI): -5.54 to -3.50], ICULOS (-3.40 days; 95% CI: -6.01 to -0.79), HLOS (-3.82 days; 95% CI: -7.12 to -0.54), and decreased mortality (pooled RR: 0.44; 95% CI: 0.28-0.69), pneumonia (0.45; 95% CI: 0.30-0.69), and tracheostomy (0.25; 95% CI: 0.13-0.47). CONCLUSIONS: As compared with nonoperative therapy, operative fixation of FC is associated with reductions in DMV, LOS, mortality, and complications associated with prolonged MV. These findings support the need for an adequately powered clinical study to further define the role of this intervention.

Perspectives of surrogate decision makers for critically ill patients regarding gene variation research.

PURPOSE: We undertook this investigation to explore the manner in which surrogate decision makers for critically ill patients perceived genetic data collected in the context of clinical investigation. METHODS: Surrogate decision makers for critically ill patients cared for in intensive care units of two urban hospitals participated in focus groups designed to explore perceptions regarding gene variation research. RESULTS: Surrogate decision makers were generally familiar with genetic concepts and reported that they could provide an informed opinion regarding permitting (or declining) the participation of their loved ones in gene variation research. Respondents perceived the risk associated with this type of research largely as the risk associated with acquiring the sample (i.e., whether it involved an invasive procedure or not) but appreciated that genetic samples could provide information not readily obtained from nongenetic sources. Concerns about potential misuse of genetic data largely centered on misconduct, paternity, forensic applications, and insurance and employment discrimination. Although surrogate decision makers expressed that their loved ones would have interest in return of results and being recontacted for future use, these interests were secondary to confidentiality concerns. CONCLUSION: Respondents perceived genetic and nongenetic data as comparable. Informed consent processes that provide clear information regarding confidentiality protections, specimen handling, and parameters for future use may enhance enrollment.Genet Med 2013:15(5):368-373.

Tracheostomy practice in adults with acute respiratory failure.

OBJECTIVE: Tracheostomy remains one of the most commonly performed surgical procedures in adults with acute respiratory failure and identifies a patient cohort which is among the most resource-intensive to provide care. The objective of this concise definitive review is the synthesis of current knowledge regarding tracheostomy practice in this context. DATA SOURCE: Peer-reviewed, English language publications pertaining to tracheostomy indications, timing, technique, and management. RESULTS: Contemporary literature concerning tracheostomy use predominately focuses on two aspects: procedure timing and technical considerations. Three recent, large, randomized controlled trials failed to demonstrate an effect of "early" tracheostomy on mortality, infectious complications, intensive care unit, or hospital length of stay. Relative to continued translaryngeal intubation, tracheostomy was associated with less sedation use and earlier mobility. An accumulating body of literature suggests that, relative to conventional surgical methods, percutaneous dilational techniques are advantageous with respect to cost and complication profile. Literature addressing management following tracheostomy placement consists largely of single institution, nonrandomized reports, limiting the ability to formulate specific recommendations regarding this aspect of care. CONCLUSIONS: In patients who otherwise lack indication for surgical airway, clinicians should defer tracheostomy placement for at least 2 wks following the onset of acute respiratory failure to insure need for ongoing ventilatory support. Subpopulations of patients (e.g., those with acute neurological injury or stroke) may benefit from earlier tracheostomy. Percutaneous dilational tracheostomy should be considered the preferred technique for this intervention in the appropriately selected individual. Future investigations should include efforts to optimize post-tracheostomy management and to quantify tracheostomy effects on patient-centric outcomes.

Should tracheostomy practice in the setting of trauma be standardized?

PURPOSE OF REVIEW: Trauma is a common predisposing condition in patients developing acute respiratory failure. Selection criteria for tracheostomy use in trauma remain poorly defined. The purpose of this review is to discuss contemporary knowledge regarding the benefits and risks of tracheostomy and to highlight potential strategies to standardize practice. RECENT FINDINGS: A number of studies have examined the effects of tracheostomy timing on clinically important end points. In general, these studies have produced conflicting findings, and are difficult to apply clinically. As a result, tracheostomy practice varies considerably. An approach to standardizing tracheostomy practice is presented, whereby decision for tracheostomy is based, in part, on a patient's clinical trajectory. The attractiveness of such an approach is that it attempts to match use of tracheostomy to patients with a need for continued ventilatory support. SUMMARY: Variation in clinical practice is costly. To the extent that variation in tracheostomy practice reflects suboptimal use of this procedure, greater understanding of tracheostomy utility has the potential to enhance the quality of care and more effectively target resources.

Examination of non-clinical factors affecting tracheostomy practice in an academic surgical intensive care unit.

OBJECTIVES: To gain insight into nonclinical factors potentially influencing tracheostomy practice and determine whether a specialized consultation form impacts tracheostomy utilization. DESIGN: Prospective, observational. SETTING: Surgical intensive care unit (SICU). PATIENTS: Patients requiring mechanical ventilatory support. Data abstracted from the Project Impact administrative database served as a practice benchmark. INTERVENTIONS: Prospective data collection, completion of online survey, and implementation of specialized tracheostomy consultation form. MEASUREMENTS AND MAIN RESULTS: Data were prospectively collected on 539 patients and 13 attending intensivists. Our SICU tracheostomy rate (54.2%) exceeded that of 18 comparable ICUs participating in Project Impact (13.9%, p < .001). We attempted to identify factors that might account for liberal tracheostomy use. In 41.5% (+/-0.6%) of patients undergoing tracheostomy, extubation had not occurred despite successful completion of spontaneous breathing trial on >or=1 occasion, a rate that varied significantly among attending intensivists responsible for decision making for this procedure (p < .001). Attending intensivists and postgraduate surgical trainees with SICU experience were surveyed to better understand perceptions of tracheostomy practice. Most respondents (96.1%) reported relying on spontaneous breathing trial to guide decision for extubation, 72.6% estimated that

Pathway to Electroconvulsive Treatment for Minors.

The decision-making process of prescribing electroconvulsive treatment (ECT) to minors often extends outside of medicine. The legal arena is commonly involved in many jurisdictions, and some states have legislation governing the administration of this treatment in addition to hospital policies and regulations. Treatment failures, additional opinions, explicit consent, and legal tribunals are sometimes needed to deliver ECT to a minor in need. This article describes a process to which a provider can refer in navigating this confusing, and sometimes alien, pathway to provide ECT to his or her patient. Individual state statutes pertaining to ECT are provided.

Attributable mortality from extensively drug-resistant gram-negative infections using propensity-matched tracer antibiotic algorithms.

BACKGROUND: Tracer antibiotic algorithms using administrative data were investigated to estimate mortality attributable to extensively drug-resistant gram-negative infections (GNIs). METHODS: Among adult inpatients coded for GNIs, colistin cases and 2 comparator cohorts (non-carbapenem ß-lactams or carbapenems) treated for ≥4 consecutive days, or died while receiving the antibiotic, were separately propensity score-matched (1:2). Attributable mortality was the in-hospital mortality difference among propensity-matched groups. Infection characteristics and sepsis severity influences on attributable mortality were examined. Algorithm accuracy was assessed by chart review. RESULTS: Of 232,834 GNIs between 2010 and 2013 at 79 hospitals, 1,023 per 3,350 (30.5%) colistin and 9,188 per 105,641 (8.7%) ß-lactam (non-carbapenem) comparator cases died. Propensity-matched colistin and ß-lactam case mortality was 29.2% and 16.6%, respectively, for an attributable mortality of 12.6% (95% confidence interval 10.8-14.4%). Attributable mortality varied from 11.0% (7.5%-14.7%) for urinary to 15.5% (12.6%-18.4%) for respiratory (P < .0001), and 4.6% (2.1%-7.4%) for early (≤4 days) to 16.6% (14.3%-18.9%) for late-onset infections (P < .0001). Attributable mortality decreased to 7.5% (5.6%-9.4%) using a carbapenem comparator cohort but increased 9-fold in patients coded for severe sepsis or septic shock (P < .0001). Our colistin algorithm had a positive predictive value of 60.4% and sensitivity of 65.3%. CONCLUSIONS: Mortality attributable to treatment-limiting resistance during GNIs varied considerably by site, onset, and severity of infection.

Tracheostomy protocol: experience with development and potential utility.

OBJECTIVES: To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning. DESIGN: Prospective, observational data collection. SETTING: Academic medical center. PATIENTS: Surgical intensive care unit patients requiring mechanical ventilatory support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75-8.0) and 7.0 (5.0-10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0-19.0] vs. 6.0 [4.0-8.0], p < .001). For patients requiring ventilatory support for > or = 20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy. CONCLUSIONS: A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

Pharmacoepidemiology of QT-interval prolonging drug administration in critically ill patients.

PURPOSE: Commonly prescribed medications produce QT-prolongation and are associated with torsades de pointes in non-acutely ill patients. We examined patterns of QT-prolonging drug use in critically ill individuals. METHODS: An administrative critical care database was utilized to identify patients receiving drugs associated with QT-interval prolongation or torsades de pointes for > or = 24 hours. RESULTS: Data from 212 016 individuals collected over a 63-month period was examined to identify 6125 patients (2.9%) receiving QT-interval prolonging drugs. These individuals had a mean (+/-SE) age of 63.0 (+/-0.2) years, were predominately male (55.4%) and Caucasian (84.4%), and were exposed to QT-interval prolonging agents for a mean (+/-SE) 53.1 (+/-0.4)% of their ICU length of stay. Respiratory and cardiovascular illnesses were the most common reasons for ICU admission (17.2, 12.0%, respectively). The most frequently administered agents were amiodarone (23.5%), haloperidol (19.8%), and levofloxacin (19.7%); no other single agent accounted for more than 10% of QT-interval prolonging drugs prescribed. Coadministration of QT-prolonging drugs occurred in 1139 patients (18.6%). These patients had higher ICU mortality rate and longer ICU lengths of stay, compared to patients not receiving coadministered drugs (p < 0.001 for both). For patients receiving coadministered drugs, overlap occurred for 71.4 (+/-0.8)% of the time that the drugs were given. Amiodarone coadministration with antibiotics, haloperidol coadministration with antibiotics, and haloperidol coadministration with amiodarone, comprised 15.2, 13.7, and 9.4%, of all coadministered agents, respectively. CONCLUSIONS: QT-prolonging drugs were used in a minority of critically ill patients. Prospective evaluation in the ICU environment is necessary to determine whether administration of these agents is associated with adverse cardiac events comparable to those reported in ambulatory patients.

Tracheostomy Update: When and How.

Tracheostomy remains one of the most commonly performed surgical procedures in the setting of acute respiratory failure. Tracheostomy literature focuses on 2 aspects of this procedure: when (timing) and how (technique). Recent trials have failed to demonstrate an effect of tracheostomy timing on most clinically important endpoints. Nonetheless, relative to continued translaryngeal intubation, studies suggest that tracheostomy use is associated with less need for sedation and enhanced patient comfort. Evidence likewise suggests that percutaneous dilational tracheostomy is advantageous with respect to cost and complication profile and should be considered the preferred approach in appropriately selected patients.

Automatic Estimation of the Optic Nerve Sheath Diameter from Ultrasound Images.

We present an algorithm to automatically estimate the diameter of the optic nerve sheath from ocular ultrasound images. The optic nerve sheath diameter provides a proxy for measuring intracranial pressure, a life threating condition frequently associated with head trauma. Early treatment of elevated intracranial pressures greatly improves outcomes and drastically reduces the mortality rate. We demonstrate that the proposed algorithm combined with a portable ultrasound device presents a viable path for early detection of elevated intracranial pressure in remote locations and without access to trained medical imaging experts.

Is It Time to Rethink Postgraduate Training Requirements for Licensure?

Approaches to postgraduate medical training have evolved substantially in recent years, reflecting the complexity of the educational mission. Residency programs seek to produce clinicians who achieve board certification as an attestation of their competency. Certification criteria are established by the American Board of Medical Specialties, are consistent from state to state, and include periods of supervised instruction ranging from as few as three years (for primary care specialties) to much longer for selected disciplines. In contrast, minimum postgraduate training criteria necessary for licensure as an independent practitioner are established by state medical boards and vary significantly among and within jurisdictions. In most states, licenses can be granted to individuals who have completed as little as one year of postgraduate training. The discrepancy between the minimum time commitment necessary to become a competent physician and that to be licensed as an independent practitioner has implications for health care quality and safety. Data are lacking as to the number of licenses issued nationally to individuals who have only partially completed residency training and the nature of practices they pursue. Extrapolating from available evidence, these individuals may very well provide care inferior to those who have satisfied training requirements for certification eligibility and be more prone to problematic behavior resulting in disciplinary action. Efforts to establish more rigorous licensure criteria will require dialog between members of the academic community, professional organizations, state medical boards, and legislatures. The recently proposed Interstate Medical Licensure Compact may serve as a prototype for achieving this goal.

Juvenile Firesetting.

Juvenile firesetting is a significant cause of morbidity and mortality in the United States. Male gender, substance use, history of maltreatment, interest in fire, and psychiatric illness are commonly reported risk factors. Interventions that have been shown to be effective in juveniles who set fires include cognitive behavior therapy and educational interventions, whereas satiation has not been shown to be an effective intervention. Forensic assessments can assist the legal community in adjudicating youth with effective interventions. Future studies should focus on consistent assessment and outcome measures to create more evidence for directing evaluation and treatment of juvenile firesetters.