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.

Learning from terrorist mass casualty incidents: a global survey.

BACKGROUND: Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. METHODS: We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. RESULTS: Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). CONCLUSION: This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

Trauma Patients with an Open Abdomen Following Damage Control Laparotomy can be Extubated Prior to Abdominal Closure.

BACKGROUND: The open abdomen (OA) is commonly utilized as a technique during damage control laparotomy (DCL). We propose that a selected group of these OA patients can be extubated prior to abdominal closure to decrease ventilator days and risk of pneumonia. METHODS: A retrospective chart review was performed at a Level I trauma center on all adult trauma patients with an OA following DCL. Patients were stratified into two groups: extubated prior to (PRE) and extubated after (POST) abdominal closure. Successful extubation in the PRE group was measured by the absence of re-intubation. The two groups were compared using the Mann-Whitney U and Fisher's exact tests. Multivariate logistic regression identified independent predictors for successful extubation prior to abdominal closure. RESULTS: Thirty-one patients were in the PRE group, and 59 patients in the POST group. There were no differences between the groups with regard to age, gender, or hours from admission to completion of DCL. The PRE group had a significantly higher incidence of penetrating trauma (77 vs. 53%; p = 0.02), a significantly lower number of days from OA to extubation [0.6 (0.2-1.1) vs. 3.4 (2--8) days; p < 0.001], and a significant decrease in pneumonia (10 vs. 31%; p = 0.04). Two patients in each group required re-intubation [PRE (6%) vs. POST (3%); p = 0.61]. In a multivariate binominal logistic regression, penetrating trauma (p = 0.024), GCS on admission (p < 0.0001), and Injury Severity Score (p = 0.024) were identified as independent predictors for successful extubation. CONCLUSION: Presence of an OA following DCL does not require mechanical ventilation. Extubation of appropriate trauma patients prior to abdominal closure decreases pneumonia and hospital length of stay.

Prospective study examining clinical outcomes associated with a negative pressure wound therapy system and Barker's vacuum packing technique.

BACKGROUND: The open abdomen has become a common procedure in the management of complex abdominal problems and has improved patient survival. The method of temporary abdominal closure (TAC) may play a role in patient outcome. METHODS: A prospective, observational, open-label study was performed to evaluate two TAC techniques in surgical and trauma patients requiring open abdomen management: Barker's vacuum-packing technique (BVPT) and the ABThera(TM) open abdomen negative pressure therapy system (NPWT). Study endpoints were days to and rate of 30-day primary fascial closure (PFC) and 30-day all-cause mortality. RESULTS: Altogether, 280 patients were enrolled from 20 study sites. Among them, 168 patients underwent at least 48 hours of consistent TAC therapy (111 NPWT, 57 BVPT). The two study groups were well matched demographically. Median days to PFC were 9 days for NPWT versus 12 days for BVPT (p = 0.12). The 30-day PFC rate was 69 % for NPWT and 51 % for BVPT (p = 0.03). The 30-day all-cause mortality was 14 % for NPWT and 30 % for BVPT (p = 0.01). Multivariate logistic regression analysis identified that patients treated with NPWT were significantly more likely to survive than the BVPT patients [odds ratio 3.17 (95 % confidence interval 1.22-8.26); p = 0.02] after controlling for age, severity of illness, and cumulative fluid administration. CONCLUSIONS: Active NPWT is associated with significantly higher 30-day PFC rates and lower 30-day all-cause mortality among patients who require an open abdomen for at least 48 h during treatment for critical illness.

Improving efficiency and reducing costs in robotic surgery: a Lean Six Sigma approach to optimize turnover time.

Operating room (OR) turnover time (TOT) is the time it takes to prepare an OR for the next surgery after the previous one has been completed. Reducing OR TOT can improve the efficiency of the OR, reduce costs, and improve surgeons' and patients' satisfaction. The objective of this study is to evaluate the effectiveness of an operating room (OR) turnover time (TOT) reduction initiative using the Lean Six Sigma methodology (DMAIC) in the bariatric and thoracic service lines. Performance improvement strategies consist of simplifying steps (surgical tray optimization) and concurrent steps (parallel task execution). We compared 2-month pre-implementation vs. post-implementation. A paired t-test was used to assess whether the difference in the measurements was statistically significant. The study found that TOT was reduced by 15.6% from an average of 35.6 ± 8.1 to minutes 30.09 ± 9.7 min (p < 0.05). Specifically, in the bariatric service line, TOT was reduced by 17.15% and in the thoracic service line, TOT was reduced by 9.6%. No adverse events related to the initiative were reported. The results of this study indicate that the TOT reduction initiative was effective in reducing TOT. The efficient use of operating rooms is crucial in hospital management, as it not only impacts finances but also affects the satisfaction of surgical teams and patients. This study shows the effectiveness of Lean Six Sigma methodology in reducing TOT and improving the efficiency in the OR.

Vena cava filter practices of a regional vascular surgery society.

BACKGROUND: Vena cava filter (VCF) use in the United States has increased dramatically with prophylactic indications for placement and the availability of low-profile retrievable devices, which are overtaking the filter market. We surveyed the practice patterns of a large group of vascular surgeons from a regional vascular surgery society to see whether they mirrored current national trends. METHODS: A 17-question online VCF survey was offered to all members of the Southern Association of Vascular Surgery. The responses were analyzed using the χ(2) goodness of fit tests. RESULTS: Of the 276 members surveyed, 126 (46%) responded, with 118 (93%) indicating that they placed filters during their practice. Highly significant differences were identified with each question (at least P < 0.002). Regarding the inferior vena cava, the preferred permanent filters were the Greenfield (31%), the TrapEase (15%), the Vena Tech (5%), and a variety of retrievable devices (49%). Fifty percent of the respondents placed retrievable filters selectively; 26% always placed them; and 24% never did. Filters were placed for prophylactic indications <50% of the time by 63% of the respondents. Overall, retrievable filters (when not used as permanent filters) were removed <25% of the time by 64% of the respondents and <50% of the time by 78% of the respondents. The femoral vein was the preferred access site for 84% of the respondents. Major complications were few but included filter migration to the atrium (one), atrial perforation (one), abdominal pain requiring surgical filter removal (two), inferior vena cava thrombosis (12 vena cava thrombosis--4 due to TrapEase filters), strut fracture with embolization to heart or lungs (three Bard retrievable filters), and severe tilting precluding percutaneous retrieval and protection from pulmonary emboli (8 filters with severe tilt--7 of which were Bard). Of the respondents, 59% had never placed a superior vena cava filter, and 28% had placed five or fewer. CONCLUSIONS: Although VCF insertion overall appears safe, some complications are specific to biconical and certain retrievable filters. Given the low removal rate and lack of long-term experience with retrievable filters, routine use of these devices as permanent filters should be questioned. If used on a temporary basis, there should be a plan for filter removal at the time of implantation.

Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival?

OBJECTIVE: The diagnosis and management of intra-abdominal hypertension and abdominal compartment syndrome have changed significantly over the past decade with improved understanding of the pathophysiology and appropriate treatment of these disease processes. Serial intra-abdominal pressure measurements, nonoperative pressure-reducing interventions, and early abdominal decompression for refractory intra-abdominal hypertension or abdominal compartment syndrome are all key elements of this evolving strategy. DESIGN: Prospective, observational study. SETTING: Tertiary referral/level I trauma center. PATIENTS: Four hundred seventy-eight consecutive patients requiring an open abdomen for the management of intra-abdominal hypertension or abdominal compartment syndrome. INTERVENTIONS: Patients were managed by a defined group of surgical intensivists using established definitions and an evidence-based management algorithm. Both univariate and multivariate analyses were performed to identify patient and management factors associated with improved survival. MEASUREMENTS AND MAIN RESULTS: Whereas patient demographics and severity of illness remained unchanged over the 6-yr study period, the use of a continually revised intra-abdominal hypertension/abdominal compartment syndrome management algorithm significantly increased patient survival to hospital discharge from 50% to 72% (p = .015). Clinically significant decreases in resource utilization and an increase in same-admission primary fascial closure from 59% to 81% were recognized. Development of abdominal compartment syndrome, prophylactic use of an open abdomen to prevent development of intra-abdominal hypertension/abdominal compartment syndrome, and use of a multi-modality surgical/medical management algorithm were identified as independent predictors of survival. CONCLUSIONS: A comprehensive evidence-based management strategy that includes early use of an open abdomen in patients at risk significantly improves survival from intra-abdominal hypertension/abdominal compartment syndrome. This improvement is not achieved at the cost of increased resource utilization and is associated with an increased rate of primary fascial closure.

Injury characteristics of the Pulse Nightclub shooting: Lessons for mass casualty incident preparation.

BACKGROUND: On the morning of June 12, 2016, an armed assailant entered the Pulse Nightclub in Orlando, Florida, and initiated an assault that killed 49 people and injured 53. The regional Level I trauma center and two community hospitals responded to this mass casualty incident. A detailed analysis was performed to guide hospitals who strive to prepare for future similar events. METHODS: A retrospective review of all victim charts and/or autopsy reports was performed to identify victim presentation patterns, injuries sustained, and surgical resources required. Patients were stratified into three groups: survivors who received care at the regional Level I trauma center, survivors who received care at one of two local community hospitals, and decedents. RESULTS: Of the 102 victims, 40 died at the scene and 9 died upon arrival to the Level I trauma center. The remaining 53 victims received definitive medical care and survived. Twenty-nine victims were admitted to the trauma center and five victims to a community hospital. The remaining 19 victims were treated and discharged that day. Decedents sustained significantly more bullet impacts than survivors (4 ± 3 vs. 2 ± 1; p = 0.008) and body regions injured (3 ± 1 vs. 2 ± 1; p = 0.0002). Gunshots to the head, chest, and abdominal body regions were significantly more common among decedents than survivors (p < 0.0001). Eighty-two percent of admitted patients required surgery in the first 24 hours. Essential resources in the first 24 hours included trauma surgeons, emergency room physicians, orthopedic/hand surgeons, anesthesiologists, vascular surgeons, interventional radiologists, intensivists, and hospitalists. CONCLUSION: Mass shooting events are associated with high mortality. Survivors commonly sustain multiple, life-threatening ballistic injuries requiring emergent surgery and extensive hospital resources. Given the increasing frequency of mass shootings, all hospitals must have a coordinated plan to respond to a mass casualty event. LEVEL OF EVIDENCE: Epidemiological Study, level V.

Antiplatelet Agent Reversal Is Unnecessary in Blunt Traumatic Brain Injury Patients Not Requiring Immediate Craniotomy.

BACKGROUND: The need to reverse the coagulation impairment caused by chronic antiplatelet agents in traumatic brain injury (TBI) patients with acute traumatic intracerebral hemorrhage (TICH) remains controversial. We sought to determine whether emergent platelet transfusion reduces the incidence of hemorrhage expansion, mortality, or need for neurosurgical intervention such as intracranial pressure (ICP) monitoring, burr holes, or craniotomy. METHODS: All adult blunt TICH patients (age ≥16 years) over a 4-year period were retrospectively reviewed. Patients with penetrating TBI, blunt TBI without TICH on admission computed tomography (CT), receiving warfarin, not on antiplatelet agents, or requiring immediate operative intervention were excluded. Patients were divided into 2 groups depending on whether they received a platelet transfusion: reversal group (RV) versus no reversal group (NR). Patient outcomes were analyzed using Mann-Whitney U and Fisher's exact tests. RESULTS: 169 blunt TBI patients on chronic antiplatelet therapy were studied (102 RV group, 67 NR group). The groups were well matched with regard to age, Injury Severity Score, Abbreviated Injury Scale-head, Glasgow Coma Score, mechanism of injury, need for intubation, time to initial CT scan, and hospital length of stay. Immediate platelet transfusion did not alter the occurrence of TICH extension on follow-up CT (26% vs 21%, P = .71), TBI-specific mortality (9% vs 13%, P = .45), need for ICP monitor (2% vs 3%, P = 1.0), burr hole (1% vs 3%, P = .56), or craniotomy (1% vs 3%, P = .56). DISCUSSION: Immediate platelet transfusion is unnecessary in blunt TBI patients on chronic antiplatelet therapy who do not require immediate craniotomy.

The impact of body position on intra-abdominal pressure measurement: a multicenter analysis.

OBJECTIVE: Elevated intra-abdominal pressure (IAP) is a frequent cause of morbidity and mortality among the critically ill. IAP is most commonly measured using the intravesicular or "bladder" technique. The impact of changes in body position on the accuracy of IAP measurements, such as head of bed elevation to reduce the risk of ventilator-associated pneumonia, remains unclear. DESIGN: Prospective, cohort study. SETTING: Twelve international intensive care units. PATIENTS: One hundred thirty-two critically ill medical and surgical patients at risk for intra-abdominal hypertension and abdominal compartment syndrome. INTERVENTIONS: Triplicate intravesicular pressure measurements were performed at least 4 hours apart with the patient in the supine, 15 degrees , and 30 degrees head of bed elevated positions. The zero reference point was the mid-axillary line at the iliac crest. MEASUREMENTS AND MAIN RESULTS: Mean IAP values at each head of bed position were significantly different (p < 0.0001). The bias between IAPsupine and IAP15 degrees was 1.5 mm Hg (1.3-1.7). The bias between IAPsupine and IAP30 degrees was 3.7 mm Hg (3.4-4.0). CONCLUSIONS: Head of bed elevation results in clinically significant increases in measured IAP. Consistent body positioning from one IAP measurement to the next is necessary to allow consistent trending of IAP for accurate clinical decision making. Studies that involve IAP measurements should describe the patient's body position so that these values may be properly interpreted.

Abdominal compartment syndrome.

PURPOSE OF REVIEW: Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS), the pathophysiologic implications of elevated intraabdominal pressure (IAP), have detrimental effects on all organ systems and are associated with significant morbidity and mortality. Within the past few years, the diagnosis and management of these syndromes have evolved tremendously. RECENT FINDINGS: Consensus definitions and recommendations for the diagnosis and management of IAH/ACS have been proposed. Risk factors for IAH/ACS have been clearly defined. The timing and techniques for IAP measurement have been further described. A comprehensive evidence-based medical and surgical approach to the treatment of IAH/ACS has been developed. SUMMARY: Liberal IAP measurement in the presence of known risk factors combined with implementation of an evolving and comprehensive resuscitation strategy have resulted in significant improvements in both short and long-term outcome for patients who develop IAH/ACS. All clinicians should be aware of the risk factors that predict development of IAH/ACS, the appropriate measurement of IAP, and the current resuscitation options for managing these highly morbid syndromes.

Nonoperative management of intraabdominal hypertension and abdominal compartment syndrome.

Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have detrimental effects on all organ systems and are associated with significant morbidity and mortality. In recent years, the diagnosis and management of these syndromes has evolved tremendously, and the importance of comprehensive strategies to reduce intraabdominal pressure (IAP) has been recognized. All clinicians should be aware of the risk factors that predict the development of IAH/ACS, the appropriate measurement of IAP, and the current resuscitation options for managing these highly morbid syndromes. The nonoperative management of IAH/ACS can be summarized using five therapeutic goals: evacuate intraluminal contents, evacuate intraabdominal space-occupying lesions, improve abdominal wall compliance, optimize fluid administration, and optimize systemic and regional tissue perfusion. Surgical intervention through open abdominal decompression should immediately be pursued for patients with progressive IAH, end-organ dysfunction, and failure that is refractory to these nonoperative therapies. This comprehensive management strategy has been demonstrated to improve patient survival and long-term outcome.

Classification--important step to improve management of patients with an open abdomen.

This short report is a distillation of the proceedings from a consensus group meeting in January 2009. It outlines a proposed classification system for patients with an open abdomen (OA). The classification allows (1) a description of the patient's clinical course; (2) standardized clinical guidelines for improving OA management; and (3) improved reporting of OA status, which will facilitate comparisons between studies and heterogeneous patient populations. The following grading is suggested: grade 1A, clean OA without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization); grade 1B, contaminated OA without adherence/fixity; grade 2A, clean OA developing adherence/fixity; grade 2B, contaminated OA developing adherence/fixity; grade 3, OA complicated by fistula formation; grade 4, frozen OA with adherent/fixed bowel, unable to close surgically, with or without fistula. We propose that this classification system will facilitate communication, clarify OA management, and potentially improve patient care.

Mass shootings: Are children safer in the streets than in the home?

PURPOSE: Though the total fatality and injury count in mass shootings is known, the burden on the pediatric population remains undefined. We sought to define the impact of domestic vs. public mass shootings in the pediatric population. METHODS: Open-source databases, Everytown for Gun Violence, and Mother Jones were cross-referenced and used to review domestic and public mass shootings from 2009 to 2016. Mass shootings were defined as four or more fatalities and any injuries. Domestic mass shootings were defined as ones that occurred in the home where the assailant was either a family member or a past or present intimate partner of a family member. Public mass shootings occurred in a public space where the shooter was unknown to the victim. The number of incidents in each group, fatalities and injuries, and effect on children <18 years were analyzed along with perpetrator characteristics. Categorical data were analyzed using Fisher's Exact test. RESULTS: There were 71 Domestic and 31 Public mass shootings accounting for 331 vs. 281 fatalities and 28 vs. 217 injuries (p < 0.0001). Children <18 years accounted for 44% of Domestic and 10% of Public fatalities (p < 0.0001) and 46% vs. 2% of all injuries (p < 0.0001). The assailant was prohibited from owning or possessing a firearm in 32% of Domestic and 39% of Public mass shootings accounting for 54 vs. 25 fatalities. CONCLUSION: The pediatric fatality rate in mass shootings is alarming, especially among Domestic shooting events. This is a public health issue and requires vigilance to protect at-risk youth. TYPE OF STUDY: Epidemiology study, retrospective review. LEVEL OF EVIDENCE: Level IV.

The effect of different reference transducer positions on intra-abdominal pressure measurement: a multicenter analysis.

OBJECTIVE: To investigate the effect of different reference transducer positions on intra-abdominal pressure (IAP) measurement. Three reference levels were studied: the symphysis pubis; the phlebostatic axis; and the midaxillary line at the level of the iliac crest. DESIGN: Prospective cohort study. SETTING: The intensive care units of participating hospitals PATIENTS AND PARTICIPANTS: One hundred thirty-two critically ill patients at risk for intra-abdominal hypertension (IAH). INTERVENTIONS: In each patient, three sets of IAP measurements were obtained in the supine position, using the different reference levels. The IAP measurements obtained at the different reference levels were compared using a paired t-test and Bland-Altman statistics were calculated. MEASUREMENTS AND RESULTS: IAP(phlebostatic) (9.9 +/- 4.67 mmHg) and IAP(pubis) (8.4 +/- 4.60 mmHg) were significantly lower that IAP(midax) (12.2 +/- 4.66 mmHg; p < 0.0001 for both comparisons). The bias between the IAP(midax) and IAP(pubis) was 3.8 mmHg (95% CI 3.5-4.1) and 2.3 mmHg (95% CI 1.9-2.6) between the IAP(midax) and the IAP(phlebostatic). The precision was 3.03 and 3.40, respectively. CONCLUSIONS: In the supine position, IAP(midax) is higher than both IAP(phlebostatic) and IAP(pubis), differences found to be clinically significant; therefore, the symphysis pubis or phlebostatic axis reference lines are not interchangeable with the midaxillary level.

Intraabdominal pressure monitoring during fluid resuscitation.

PURPOSE OF REVIEW: Elevated intraabdominal pressure is commonly encountered in the critically ill, has detrimental effects on all organ systems, and is associated with significant morbidity and mortality. Serial intraabdominal pressure measurements are essential to the diagnosis, management, and fluid resuscitation of patients who develop intraabdominal hypertension and/or abdominal compartment syndrome. RECENT FINDINGS: Over the past year, the importance of intraabdominal pressure measurements and their accurate determination has been further defined. Several nonoperative therapies have been demonstrated to reduce the morbidity and mortality of intraabdominal hypertension/abdominal compartment syndrome, all of which are guided by measurements of intraabdominal pressure. The World Society of the Abdominal Compartment Syndrome has published evidence-based medicine consensus guidelines for the measurement of intraabdominal pressure and its utilization in the diagnosis and resuscitation of the critically ill. SUMMARY: Serial intraabdominal pressure measurements are essential for the diagnosis and management of intraabdominal hypertension/abdominal compartment syndrome. Intraabdominal pressure must be measured accurately and utilized in a goal-directed fashion to guide fluid and end-organ resuscitation. As a result of its ability to predict survival among the critically ill, intraabdominal pressure should be routinely monitored in the patient who demonstrates risk factors for intraabdominal hypertension/abdominal compartment syndrome.

The death of George Washington: an end to the controversy?

The controversy surrounding the death of George Washington was immediate, intense, and continues today. After a horse ride in sleet and snow, Washington developed fulminant acute epiglottitis that rapidly claimed his life within 24 hours. In treatment, he endured phlebotomy of over 2500 mL as well as various other painful therapies that were the standard practice of the day. Over the years, numerous criticisms have been lodged against the care his three physicians rendered. Although the marked bloodletting has been most heavily scrutinized, others have argued that Washington could have survived had a tracheostomy been performed. Delayed presentation, prolonged Class IV hemorrhagic shock, acute respiratory failure, and probable septic shock in a 67 year old with preexisting medical comorbidities has a high mortality rate today and would have been irreversible in 1799. George Washington's inevitable death was assured by his own initial actions compounded by the treatments initiated by his physicians.

Measuring intra-abdominal pressure outside the ICU: validation of a simple bedside method.

Intra-abdominal pressure measurement is essential to the diagnosis of patients with intraabdominal hypertension or abdominal compartment syndrome. The most common method for measuring intra-abdominal pressure (IAP) is the intravesicular or "bladder" technique, which requires electronic monitoring technology not available on the typical surgical ward. Herein we describe and validate a simple, rapid screening method for bedside IAP measurement using the patient's indwelling urinary catheter and a readily available intravenous tubing extension. Validation of this technique across the clinically important IAP diagnostic spectrum demonstrated acceptable bias (1.6 mm Hg; 95% confidence interval 1.4-1.8) with limits of agreement of 0.36 to 2.8. This demonstrates good agreement between the two IAP methods and validates the bedside technique as a simple, cost-effective, and reproducible method for screening IAP measurements outside of the critical care setting.