RESUMEN
This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.
Asunto(s)
Unidades de Cuidados Intensivos/organización & administración , Guías de Práctica Clínica como Asunto , Donantes de Tejidos , Obtención de Tejidos y Órganos/organización & administración , Muerte , Humanos , Unidades de Cuidados Intensivos/normas , Derechos del Paciente , Sociedades Médicas , Obtención de Tejidos y Órganos/normas , Estados UnidosRESUMEN
One barrier for implementing programs of uncontrolled organ donation after the circulatory determination of death is the lack of consensus on the precise moment of death. Our panel was convened to study this question after we performed a similar analysis on the moment of death in controlled organ donation after the circulatory determination of death. We concluded that death could be determined by showing the permanent or irreversible cessation of circulation and respiration. Circulatory irreversibility may be presumed when optimal cardiopulmonary resuscitation efforts have failed to restore circulation and at least a 7-minute period has elapsed thereafter during which autoresuscitation to restored circulation could occur. We advise against the use of postmortem organ support technologies that reestablish circulation of warm oxygenated blood because of their risk of retroactively invalidating the required conditions on which death was declared.
Asunto(s)
Muerte , Obtención de Tejidos y Órganos/métodos , Comités Consultivos , Circulación Sanguínea , Muerte Encefálica , Reanimación Cardiopulmonar , Protocolos Clínicos , Humanos , Donantes de Tejidos , Obtención de Tejidos y Órganos/normas , Estados UnidosRESUMEN
OBJECTIVE: Death statutes permit physicians to declare death on the basis of irreversible cessation of circulatory-respiratory or brain functions. The growing practice of organ donation after circulatory determination of death now requires physicians to exercise greater specificity in circulatory-respiratory death determination. We studied circulatory-respiratory death determination to clarify its concept, practice, and application to innovative circulatory determination of death protocols. RESULTS: It is ethically and legally appropriate to procure organs when permanent cessation (will not return) of circulation and respiration has occurred but before irreversible cessation (cannot return) has occurred because permanent cessation: 1) is an established medical practice standard for determining death; 2) is the meaning of "irreversible" in the Uniform Determination of Death Act; and 3) does not violate the "Dead Donor Rule." CONCLUSIONS: The use of unmodified extracorporeal membrane oxygenation in the circulatory determination of death donor after death is declared should be abandoned because, by restoring brain circulation, it retroactively negates the previous death determination. Modifications of extracorporeal membrane oxygenation that avoid this problem by excluding brain circulation are contrived, invasive, and, if used, should require consent of surrogates. Heart donation in circulatory determination of death is acceptable if proper standards are followed to declare donor death after establishing the permanent cessation of circulation. Pending additional data on "auto-resuscitation," we recommend that all circulatory determination of death programs should utilize the prevailing standard of 2 to 5 mins of demonstrated mechanical asystole before declaring death.
Asunto(s)
Muerte , Ética Médica , Paro Cardíaco/diagnóstico , Trasplante de Corazón/ética , Obtención de Tejidos y Órganos/ética , Muerte Encefálica/legislación & jurisprudencia , Oxigenación por Membrana Extracorpórea , Trasplante de Corazón/legislación & jurisprudencia , Humanos , Obtención de Tejidos y Órganos/legislación & jurisprudencia , Estados UnidosRESUMEN
Critical care workforce analyses estimate a 35% shortage of intensivists by 2020 as a result of the aging population and the growing demand for greater utilization of intensivists. Surgical critical care in the U.S. is particularly challenged by a significant shortfall of surgical intensivists, with only 2586 surgeons currently certified in surgical critical care by the American Board of Surgery, and even fewer surgeons (1204) recertified in surgical critical care as of 2009. Surgical critical care fellows (160 in 2009) represent only 7.6% of all critical care trainees (2109 in 2009), with the largest number of critical care fellowship positions in internal medicine (1472, 69.8%). Traditional trauma fellowships have now transitioned into Surgical Critical Care or Acute Care Surgery (trauma, surgical critical care, emergency surgery) fellowships. Since adult critical care services are a large, expensive part of U.S. healthcare and workforce shortages continue to impact our healthcare system, recommendations for regionalization of critical care services in the U.S. is considered. The Critical Care Committee of the AAST has compiled national data regarding these important issues that face us in surgical critical care, trauma and acute care surgery, and discuss potential solutions for these issues.
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Cuidados Críticos , Cirugía General , Traumatología , Certificación , Becas , Cirugía General/educación , Accesibilidad a los Servicios de Salud , Necesidades y Demandas de Servicios de Salud , Humanos , Sociedades Médicas , Traumatología/educación , Estados Unidos , Recursos HumanosRESUMEN
BACKGROUND: In 2004, Christiana Care Health System (Christiana Care), a 1,100-bed tertiary care facility, used the Surviving Sepsis Campaign guidelines as the foundation for an independent initiative to reduce the mortality rate by at least 25%. METHODS: In 2004, an interdisciplinary sepsis team developed a process for rapidly recognizing at-risk patients; evaluating a patient's clinical status; and providing appropriate, timely therapy in three major areas of sepsis care; recognition of the sepsis patient, resuscitation priorities, and intensive care management. The Sepsis Alert program, which did not require additional staffing, was developed and implemented in 10 months. The Sepsis Alert packet included a care management guideline, a treatment algorithm, an emergency department treatment order set, and multiple adjuncts to streamline patient identification and management. RESULTS: Introduction of sepsis resuscitation and critical care management standards led to a 49.4% decrease in mortality rates (p < .0001), a 34.0% decrease in average length of hospital stay (p < .0002), and a 188.2% increase in the proportion of patients discharged to home (p < .0001) when the historic control group is compared with the postimplementation group from January 2005 through December 2007. DISCUSSION: An integrated leadership team, using existing resources, transformed frontline clinical practice by providers from multiple disciplines to reduce mortality in the population of patients with sepsis.
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Calidad de la Atención de Salud , Sepsis/mortalidad , Distinciones y Premios , Protocolos Clínicos , Cuidados Críticos/organización & administración , Mortalidad Hospitalaria/tendencias , Humanos , Mid-Atlantic Region , Sistemas Multiinstitucionales , Estudios de Casos OrganizacionalesRESUMEN
Intensivists frequently collaborate with plastic and reconstructive surgeons in treating patients with major wounds, following significant reconstructive procedures, and following free-tissue transfers. Pressure ulcers are a significant source of morbidity and mortality in the intensive care unit; prevention, early recognition, and multidisciplinary treatment are critical components for successful management. Necrotizing fasciitis is an aggressive, soft-tissue infection that requires rapid diagnosis, early surgical intervention frequent operative debridements, and soft-tissue reconstruction Catastrophic abdominal injuries and infections can be treated with an open abdominal approach and require the expertise of a plastic surgeon to reconstruct the abdominal wall. The success of free-tissue transfers and complex reconstructive procedures requires a thorough understanding of the factors that improve flap survival.
Asunto(s)
Procedimientos de Cirugía Plástica , Anticoagulantes/uso terapéutico , Síndromes Compartimentales/etiología , Cuidados Críticos , Descompresión Quirúrgica , Dextranos/uso terapéutico , Fascitis Necrotizante/etiología , Fibrinolíticos/uso terapéutico , Humanos , Microcirugia , Cuidados Posoperatorios , Úlcera por Presión/etiología , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos Quirúrgicos Vasculares , Cicatrización de HeridasAsunto(s)
Lesiones Encefálicas/terapia , Tiempo de Internación/estadística & datos numéricos , Centros Traumatológicos/organización & administración , Adulto , Estudios de Casos y Controles , Femenino , Escala de Coma de Glasgow , Hospitalización , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estudios RetrospectivosRESUMEN
BACKGROUND: Phlegmonous gastritis is a rare and often fatal condition that can affect healthy individuals in 50% of cases. The condition has been described in accounts dating back to the pre-antibiotic era, during which time mortality was nearly 100%. Over the past century, case reports average about one per year. The etiology remains unclear, although Streptococcus species is isolated frequently. The optimum treatment has not been delineated clearly but likely involves a combination of antibiotics with or without surgical resection. METHODS: A case report was presented and the pertinent literature was reviewed. CASE REPORT: A 45-year-old man with a history of recent paranasal sinus surgery presented with acute abdominal pain and criteria consistent with toxic shock syndrome. Computed tomography scan showed diffuse thickening of the gastric wall and free intraperitoneal fluid. Exploratory laparotomy revealed a thickened stomach wall with outer fibrinous exudate and murky peritoneal fluid, which grew Streptococcus pyogenes. Intraoperative esophagogastroduodenoscopy revealed thickened gastric folds with a "cobblestone" appearance and no evidence of perforation. He was treated with antibiotics intravenously and sustained a difficult intensive care unit course complicated by ventilator-dependent respiratory failure, renal failure, and coagulopathy, but survived without major disability. CONCLUSIONS: This is an unusual case presentation of a rare but potentially lethal condition, whose optimal treatment is unclear. Phlegmonous gastritis should be considered when isolated gastric wall thickening is encountered in the clinical setting of toxic shock syndrome.
Asunto(s)
Endoscopía/efectos adversos , Gastritis/complicaciones , Enfermedades de los Senos Paranasales/cirugía , Complicaciones Posoperatorias/microbiología , Choque Séptico/microbiología , Infecciones Estreptocócicas/diagnóstico , Streptococcus pyogenes/aislamiento & purificación , Antibacterianos/uso terapéutico , Endoscopía del Sistema Digestivo , Gastritis/microbiología , Gastritis/patología , Humanos , Laparotomía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/patología , Radiografía Abdominal , Choque Séptico/patología , Infecciones Estreptocócicas/patología , Tomografía por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVE: A widely held belief contends that food-induced proton pump activation is important for optimal proton pump inhibitor-induced inhibition of gastric acid secretion. This study was undertaken to assess intragastric acid control with intravenous (IV) esomeprazole in critically ill patients. RESEARCH DESIGN AND METHODS: This open-label, single-arm, exploratory trial was conducted at five university or regional hospital intensive care units in the US. Adult patients admitted to an intensive care unit who required mechanical ventilation and had at least one additional risk factor for stress-induced ulcer received twice-daily IV esomeprazole 40 mg for 48 hours and could continue for another 24 hours if no prepyloric enteral feedings were planned. CLINICAL TRIAL REGISTRATION: D9612L00107; ClinicalTrials.gov Identifier NCT00428701. MAIN OUTCOME MEASURES: The primary efficacy variable was the linear-interpolated percentage of time intragastric pH was > or =4 during 24-48 hours. Secondary efficacy variables included the interpolated percentage of time intragastric pH was > or =4 during 0-24, 0-48, and 48-72 hours, the percentage of gastric aspirates collected with pH > or =4 during 0-24, 24-48, 0-48, and 48-72 hours, and time to stable pH > or =4. Safety was assessed based on adverse events (AEs), physical examinations, vital signs, laboratory tests, and electrocardiograms. RESULTS: Forty-five patients were enrolled (one was excluded because of previous partial gastrectomy). Interpolated mean percentage time pH > or =4 was 88.8%, 80.7%, and 83.5% for 24-48, 0-24, and 0-48 hours, respectively. For 0-72 hours, > or =78% of gastric aspirates had pH > or =4. Median time to stable pH was 1 hour (95% confidence interval: 0.67, 2.00). Treatment was well tolerated, with no evidence of gastrointestinal bleeding. A total of 75 AEs occurred in 34 patients, none considered treatment related. CONCLUSIONS: In this noncontrolled exploratory study, twice-daily IV esomeprazole 40 mg rapidly decreased intragastric acidity and effectively maintained pH >/=4 during 0-72 hours in fasting, critically ill, mechanically ventilated patients at high risk for stress ulcers.
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Antiulcerosos/administración & dosificación , Enfermedad Crítica , Esomeprazol/administración & dosificación , Adulto , Antiulcerosos/farmacología , Esomeprazol/farmacología , Humanos , Resultado del TratamientoRESUMEN
BACKGROUND: Human polymerized hemoglobin (PolyHeme, Northfield Laboratories) is a universally compatible oxygen carrier developed to treat life-threatening anemia. This multicenter phase III trial was the first US study to assess survival of patients resuscitated with a hemoglobin-based oxygen carrier starting at the scene of injury. STUDY DESIGN: Injured patients with a systolic blood pressure=90 mmHg were randomized to receive field resuscitation with PolyHeme or crystalloid. Study patients continued to receive up to 6 U of PolyHeme during the first 12 hours postinjury before receiving blood. Control patients received blood on arrival in the trauma center. This trial was conducted as a dual superiority/noninferiority primary end point. RESULTS: Seven hundred fourteen patients were enrolled at 29 urban Level I trauma centers (79% men; mean age 37.1 years). Injury mechanism was blunt trauma in 48%, and median transport time was 26 minutes. There was no significant difference between day 30 mortality in the as-randomized (13.4% PolyHeme versus 9.6% control) or per-protocol (11.1% PolyHeme versus 9.3% control) cohorts. Allogeneic blood use was lower in the PolyHeme group (68% versus 50% in the first 12 hours). The incidence of multiple organ failure was similar (7.4% PolyHeme versus 5.5% control). Adverse events (93% versus 88%; p=0.04) and serious adverse events (40% versus 35%; p=0.12), as anticipated, were frequent in the PolyHeme and control groups, respectively. Although myocardial infarction was reported by the investigators more frequently in the PolyHeme group (3% PolyHeme versus 1% control), a blinded committee of experts reviewed records of all enrolled patients and found no discernable difference between groups. CONCLUSIONS: Patients resuscitated with PolyHeme, without stored blood for up to 6 U in 12 hours postinjury, had outcomes comparable with those for the standard of care. Although there were more adverse events in the PolyHeme group, the benefit-to-risk ratio of PolyHeme is favorable when blood is needed but not available.
Asunto(s)
Sustitutos Sanguíneos/administración & dosificación , Hemoglobinas/administración & dosificación , Hipotensión/terapia , Choque Hemorrágico/terapia , Heridas y Lesiones/complicaciones , Adulto , Anciano , Soluciones Cristaloides , Servicios Médicos de Urgencia , Transfusión de Eritrocitos , Femenino , Fluidoterapia , Humanos , Hipotensión/etiología , Soluciones Isotónicas/administración & dosificación , Masculino , Persona de Mediana Edad , Soluciones para Rehidratación/administración & dosificación , Choque Hemorrágico/etiología , Análisis de Supervivencia , Centros Traumatológicos , Estados Unidos , Población UrbanaRESUMEN
BACKGROUND: Successfully managing pain for the trauma patient decreases morbidity, improves patient satisfaction, and is an essential component of critical care. Using patient-controlled analgesia (PCA) morphine to control pain may be complicated by concerns of respiratory depression, hemodynamic instability, addiction, urinary retention, and drug-induced ileus. Morphine is rapidly absorbed by mucosal surfaces in the respiratory tract, achieving systemic concentrations equal to 20% of equivalent intravenous doses. The purpose of this study was to evaluate the safety, efficacy, and utility of nebulized morphine in patients with posttraumatic thoracic pain. METHODS: This double-blinded, prospective study randomized patients with severe posttraumatic thoracic pain into two groups. The experimental group (NMS) received nebulized morphine every 4 hours and normal saline by PCA. The control group (PCA) received nebulized saline every 4 hours and morphine by PCA. Dose adjustments were made based on patient response to treatments using a 10-point visual analog scale (VAS) for pain. Pulmonary function, pain relief (VAS), level of sedation (0-3), total drug administration, and systematic side effects were recorded. RESULTS: Forty-four patients were randomized (22 per group). Seven hundred seventy observations were made. The mean 4-hour dose of morphine was 11.96 +/- 3.4 mg for NMS and 6.22 +/- 4.7 mg for PCA (p < 0.001). Patients with NMS had lower heart rates compared with PCA (79 +/- 11 bpm versus 92 +/- 12 bpm; p < 0.001) and were less sedated (0.33 +/- 0.7 versus 0.56 +/- 0.9; p = 0.03). The mean pain level (VAS) was 3.38 +/- 1.8 for NMS and 3.84 +/- 2.7 for PCA (p = 0.2). There was no difference between pain levels before and after dosing. There were no differences between groups with respect to arterial blood pressure, respiratory rate, vital capacity, mean forced expiratory volume in 1 second, spirometric volumes, or Sao2. CONCLUSION: Nebulized morphine can be safely and effectively used to control posttraumatic thoracic pain. Pain can be successfully managed while vital capacity, mean forced expiratory volume in one second, and spirometric volumes are maintained. Compared with PCA morphine, nebulized morphine provides equivalent pain relief with less sedative effects.
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Morfina/administración & dosificación , Dolor/tratamiento farmacológico , Heridas y Lesiones/complicaciones , Enfermedad Aguda , Administración por Inhalación , Anciano , Analgesia Controlada por el Paciente , Método Doble Ciego , Femenino , Humanos , Infusiones Intraarteriales , Masculino , Persona de Mediana Edad , Dolor/etiología , Dimensión del Dolor , Estudios Prospectivos , Fracturas de las Costillas/complicaciones , TóraxRESUMEN
OBJECTIVE: The purpose of this study was to assess the utility of two levels of hyperglycemia as predictors for mortality and infectious morbidity in traumatically injured patients. METHODS: All patients >or= 17 years old presenting to a Level I trauma center as a "trauma alert" or a "trauma code" from January 1, 2000, through December 31, 2000, were reviewed. Hypoglycemic patients (glucose concentration < 70 mg/dL) were excluded (n = 4). Patients were considered hyperglycemic with an admission glucose concentration > 200 mg/dL (moderate hyperglycemia) or an admission glucose concentration in the upper quartile for the group (mild hyperglycemia [glucose concentration > 135 mg/dL]). RESULTS: Seven hundred thirty-eight patients were included in the study. Hyperglycemia was associated with increased mortality among both patients with moderate hyperglycemia (34.1% vs. 3.7%, p < 0.01) and those with mild hyperglycemia (15.5% vs. 2%, p < 0.01) compared with corresponding normoglycemic groups. Hyperglycemia proved to be an independent predictor of mortality and of hospital and intensive care unit length of stay after multiple logistic regression while controlling for age, Injury Severity Score, Revised Trauma Score, and gender. Infectious complications, including pneumonia (9.4% vs. 2%, p = 0.001), urinary tract infections (6.6% vs. 1.4%, p = 0.001), wound infections (4.9% vs. 0.6%, p = 0.039), and bacteremia (5% vs. 1.1%, p = 0.004), were significantly increased in patients with elevated glucose concentrations. Hyperglycemia is an independent predictor of increased infectious morbidity controlling for age, gender, and Injury Severity Score in multiple logistic regression models. CONCLUSION: Hyperglycemia independently predicts increased intensive care unit and hospital length of stay and mortality in the trauma population. It is associated with increased infectious morbidity. These associations hold true for mild hyperglycemia (glucose concentration > 135 mg/dL) and moderate hyperglycemia (glucose concentration > 200 mg/dL).
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Hiperglucemia/complicaciones , Heridas y Lesiones/complicaciones , Adulto , Glucemia , Intervalos de Confianza , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Heridas y Lesiones/mortalidadRESUMEN
BACKGROUND: The value of an in-house trauma surgeon is debated. Previous studies focus on comparing in-house and on-call surgeons at different institutions or different periods in time. The purpose of this study was to simultaneously evaluate in-house and on-call trauma surgeons in a single Level I trauma center and to determine the impact of in-house trauma surgeons on the mortality of severely injured patients. METHODS: All records were reviewed for patients classified as major resuscitations from July 1997 through November 1999. Multiple logistic regression was performed to determine predictors of mortality on the basis of trauma surgeon status (in-house vs. on-call) and response time, while controlling for Injury Severity Score (ISS) and Revised Trauma Score. RESULTS: Of the 4,278 admissions, 537 were trauma codes. Mean ISS was 20.16 +/- 11.59. There was no difference between groups admitted by in-house surgeons versus on-call surgeons with respect to ISS or Revised Trauma Score. Mortality for the group was 24.8% (133 of 537); no statistical difference existed between observed and expected mortality by TRISS. The average response time was 3.96 minutes for the in-house group and 14.70 minutes for the on-call group (p < 0.001). Neither the call status nor the response time of the trauma surgeon significantly decreased emergency department or hospital mortality. There was a trend for improved outcome in those patients cared for by an in-house surgeon who were upgraded to a code, transferred into the institution, admitted during the night, or neurologically impaired. This trend did not reach statistical significance. CONCLUSION: When the trauma surgeon was rapidly available (< 15 minutes), there was no difference in emergency department or hospital mortality between in-house and on-call trauma surgeons. Selected subgroups of severely injured patients may benefit from an in-house trauma surgeon. If trauma surgeons are not readily available in an institution, an in-house call policy may be necessary for the prompt resuscitation of critically ill patients.