Hemodilution Then Hemoconcentration after Resuscitation of Patients with Severe Sepsis or Septic Shock.

BACKGROUND: The impact of fluid ri suscitation on hematologic parameters and function has been well studied in hemorrhagic shock. Similar research has not been conducted in resuscitation of septic shock. HYPOTHESIS: In the absence of accompanying hemorrhage, resuscitation of patients with sepsis should be marked by hemodilution, followed by hemoconcentration during recovery. METHODS: Records of patients with primary diagnoses of severe sepsis or septic shock treated in a community hospital intensive care unit (ICU) between 2009 and 2012 were extracted from an electronic d tabase for analysis. Demographic, physiologic, an laboratory values were recorded at daily intervals. RESULTS: 132 patients with an average age of 70. (SD 15.1) years and Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 15. (6.0) were studied. Patients spent an average of 10. (9.9) days in the ICU and 18.9 (12.0) days in hospita 19 (14.4%) did not survive hospitalization. Mean admission hematocrit was 34.8 (6.5%), and lo"m est hematocrit, adjusted for (average 0.2 U PRBC) transfusions, 25.3 (5.1)% (P < .001), occurred after an average of four days of treatment, and 7.2 (5.4 L of cumulative positive fluid balance. By day 10 adjusted hematocritincreased to 26.9(8.1) (P =.006' 'Ihere was a significant (P < .001) albeit loose correlation (R = .35) of cumulative positive fluid balance associated with lowest hematocrit. CONCLUSION: Fluid resuscitation of patients with severe sepsis or septic shock is marked by initial reductions of hematocrit followed by increases during recovery, as fluid is mobilized.

An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine.

RATIONALE: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs. OBJECTIVES: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting. METHODS: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law. MAIN RESULTS: The policy recommendations are based on the dual goals of protecting patients' access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a "shield" to protect individual clinicians' moral integrity rather than as a "sword" to impose clinicians' judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient's or surrogate's timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician's CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting. CONCLUSIONS: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians' COs in the critical care setting.

Ventilator Settings Can Substantially Impact Patients' Comfort.

BACKGROUND: With increasing realization that sedatives may complicate care of mechanically ventilated patients, greater emphasis might turn to promoting comfort by titration of ventilator settings. HYPOTHESIS: Patients with acute on chronic respiratory failure (ACRF) with underlying chronic obstructive pulmonary disease (COPD) demonstrate different levels of comfort in response to varying ventilator settings compared to those with underlying obesity hypoventilation syndrome (OHS). METHODS: Patients recovering from ACRF with underlying COPD or OHS were randomized to varying combinations of ventilator modes (assist control and pressure support), tidal volumes, and inspiratory flows for 3 minutes/setting. For each ventilator setting, physiologic variables were recorded and patients indicated their level of comfort using a 10-point Borg scale. RESULTS: In all, 20 patients, aged 68 ± 13 years (standard deviation) and ventilated for 4.9 days, were enrolled. Of 20 patients, 13 had COPD and 7 had OHS. No ventilator mode, flow, or tidal volume provided consistently greater comfort between the groups, but patients reported substantial ranges of comfort (up to 8 Borg points) across the ventilator settings studied. There were no significant differences in heart rate, blood pressure, or airway pressures within patients across ventilator settings or between the groups, but patients with OHS were more tachypneic compared to patients with COPD while breathing on assist control of 6 mL/kg (constant flow 60 L/min) and 8 mL/kg (decelerating flow 40 L/min). There was no correlation between comfort and systolic blood pressure, heart rate, or respiratory rate. CONCLUSION: Ventilator parameters may impact patients' comfort substantially. Future studies may help identify evidence-based methodology for gauging comfort following changes in ventilator settings and the settings that are most likely to positively impact various groups of patients.

Seeking worldwide professional consensus on the principles of end-of-life care for the critically ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) study.

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.

Health care unions response: fortifying clinicians' patient advocacy.

In a previous article in this point-counter-point, I argued that work actions could be ethically problematic and undermine clinicians' values and goals. I now respond to the elegant arguments made by Ash and colleagues, presenting additional measures that may be required-until health care unions (if ever) grow-to fortify protections for clinicians who advocate for patient safety and medical professionalism.

Labor unions in medicine: the intersection of patient advocacy and self-advocacy.

BACKGROUND: Labor unions have been a weak force in the medical marketplace. OBJECTIVES: To briefly review the history of physicians' and nurses' labor unions, explore the ethics of unions in medicine, and offer a solution that simultaneously serves patients and professionals. RESEARCH DESIGN: A selective review of the literature. RESULTS: Labor unions of medical professionals pose an ethical quandary, that is a tension between selfless patient advocacy versus self-advocacy. The primary role of labor unions has been to extract from management benefits for employees. The threat of work actions is the primary tool that labor unions can apply to encourage management to negotiate mutually acceptable conditions of employment. Work actions-namely slow-downs and strikes-may harm patients and may therefore run afoul of professionals' primary duty to the primacy of patients' welfare. An alternative model is offered wherein medical unions align self-centered and patient-centered interests and leverage the Public Good, in the form of public opinion, to encourage good-faith bargaining with management. CONCLUSIONS: As medicine becomes increasingly corporatized, physicians will join nurses in "at-will employment" arrangements whereby self-advocacy and patient advocacy may be impacted. Although labor unions have been a means of counterbalancing unchecked discretion of corporate management, conventional labor unions may run afoul of medical ethical principles. Reconsideration and innovation, to address this ethical dilemma, could provide a solution that aligns both clinicians' and patients' welfare.

On the Outcome Project.

BACKGROUND: In 2001, graduate medical education in the United States was renovated to better complement 21st century developments in American medicine, society, and culture. As in 1910, when Abraham Flexner was charged to address a relatively non-standardized system that lacked accountability and threatened credibility of the profession, Dr. David Leach led the Accreditation Council of Graduate Medical Education (ACGME) Outcome Project in a process that has substantially changed medical pedagogy in the United States. METHODS: Brief review of the Flexner Report of 1910 and 6 hours of interviews with leaders of the Outcome Project (4 hours with Dr. David Leach and 1-hour interviews with Drs. Paul Batalden and Susan Swing). RESULTS: Medical educational leaders and the ACGME concluded in the late 1990s that medical education was not preparing clinicians sufficiently for lifelong learning in the 21st century. A confluence of medical, social, and historic factors required definitions and a common vocabulary for teaching and evaluating medical competency. After a deliberate consensus-driven process, the ACGME and its leaders produced a system requiring greater accountability of learners and teachers, in six explicitly defined domains of medical "competence." While imperfect, this construct has started to take hold, creating a common vocabulary for longitudinal learning, from undergraduate to post-graduate (residency) education and in the assessment of performance following graduate training.

On Medicaid and the Affordable Care Act in Connecticut: the problem with subspecialty services.

BACKGROUND: Medicaid is the federal program, administered by states, for health care for the poor. The Affordable Care Act (ACA) has added a large number of new recipients to this program. HYPOTHESIS: Medicaid programs in some, if not many, states do not provide patients uniform access to subspecialty care guaranteed by the federal statutes. Insofar as the ACA does not address this pre-existing "sub-specialty gap" and more patients are now covered by Medicaid under the ACA, the gap is likely to increase and may contribute to disparities of health care access and outcomes. METHODS: A brief description of previous studies demonstrating or suggesting a subspecialty gap in Medicaid services is accompanied by perspectives of the authors, using published literature - most notably the Denver, Colorado health care system - to propose various solutions that may be deployed to address gaps in subspecialty coverage. RESULTS: All published studies describing the Medicaid subspecialty gap are qualitative, survey designs. There are no authoritative objective data regarding the exact prevalence of gaps for each subspecialty in each state. However, surveys of caregivers suggest that gaps were prevalent in the United States prior to initiation of the ACA. Even fewer papers have addressed solutions (in light of the paucity of data describing the magnitude of the problem), and proposed solutions remain speculative and not grounded in objective data. CONCLUSIONS: There is reason to believe that a substantial proportion of U.S. citizens - those who are guaranteed a full complement of health services through Medicaid - have difficult or no access to some subspecialty services, many of which other citizens take for granted. This problem deserves greater attention to verify its existence, quantify its magnitude, and develop solutions.

Perseverant, non-indicated treatment of obese patients for obstructive lung disease.

BACKGROUND: Bronchodilators are a mainstay of treatment for patients with airflow obstruction. We hypothesized that patients with obesity and no objective documentation of airflow obstruction are inappropriately treated with bronchodilators. METHODS: Spirometric results and medical records of all patients with body mass index >30 kg/m2 who were referred for testing between March 2010 and August 2011 were analyzed. RESULTS: 155 patients with mean age of 52.6 ± (SE)1.1 y and BMI of 38.7 ± 0.7 kg/m2 were studied. Spirometry showed normal respiratory mechanics in 62 (40%), irreversible airflow obstruction in 36 (23.2%), flows suggestive of restriction in 35 (22.6%), reversible obstruction, suggestive of asthma in 11 (7.1%), and mixed pattern (obstructive and restrictive) in 6 (3.9%). Prior to testing, 45.2% (28 of 62) of patients with normal spirometry were being treated with medications for obstructive lung diseases and 33.9% (21 of 62) continued them despite absence of airflow obstruction on spirometry. 60% (21 of 35) of patients with a restrictive pattern in their spirometry received treatment for obstruction prior to spirometry and 51.4% (18 of 35) continued bronchodilator therapy after spirometric testing. There was no independent association of non-indicated treatment with spirometric results, age, BMI, co-morbidities or smoking history. All patients with airflow obstruction on testing who were receiving bronchodilators before spirometry continued to receive them after testing. CONCLUSION: A substantial proportion of patients with obesity referred for pulmonary function testing did not have obstructive lung disease, but were treated nonetheless, before and after spirometry demonstrating absence of airway obstruction.

The brave new world revealed: wrestling with reality, rationing, and rationality.

When Dr. Joseph Lynch, editor of Seminars in Respiratory and Critical Care Medicine, invited us to organize and edit this topic we-and our contributors-were initially baffled about how we could marry outcomes, ethics, and economics. His perspective as an elder-statesman, who has observed the evolution of critical care medicine over 4 decades, provided perspective as to how these three areas are intimately related and that their synthesis is essential if the US medical system is to best serve our populace as resources become increasingly limited.

Team science and critical care.

Because critical care is administered by multidisciplinary teams, it is plausible that behavioral methods to enhance team performance may impact the quality and outcomes of care. This review highlights the social and behavioral scientific principles of team building and briefly reviews four features of teams--leadership, psychological safety, transactive memory, and accountability--that are germane to critical care teams. The article highlights how team principles might be used to improve patient care and navigate hospital hierarchies, and concludes with implications for future educational and scientific efforts.

Antimicrobial stewardship for sepsis in the intensive care unit: Survey of critical care and infectious diseases physicians.

OBJECTIVE: To evaluate the attitudes of infectious diseases (ID) and critical care physicians toward antimicrobial stewardship in the intensive care unit (ICU). DESIGN: Anonymous, cross-sectional, web-based surveys. SETTING: Surveys were completed in March-November 2017, and data were analyzed from December 2017 to December 2019. PARTICIPANTS: ID and critical care fellows and attending physicians. METHODS: We included 10 demographic and 17 newly developed, 5-point, Likert-scaled items measuring attitudes toward ICU antimicrobial stewardship and transdisciplinary collaboration. Exploratory principal components analysis (PCA) was used for data reduction. Multivariable linear regression models explored demographic and attitudinal variables. RESULTS: Of 372 respondents, 315 physicians had complete data (72% attendings, 28% fellows; 63% ID specialists, and 37% critical care specialists). Our PCA yielded a 3-item factor measuring which specialty should assume ICU antimicrobial stewardship (Cronbach standardized α = 0.71; higher scores indicate that ID physicians should be stewards), and a 4-item factor measuring value of ICU transdisciplinary collaborations (α = 0.62; higher scores indicate higher value). In regression models, ID physicians (vs critical care physicians), placed higher value on ICU collaborations and expressed discomfort with uncertain diagnoses. These factors were independently associated with stronger agreement that ID physicians should be ICU antimicrobial stewards. The following factors were independently associated with higher value of transdisciplinary collaboration: female sex, less discomfort with uncertain diagnoses, and stronger agreement with ID physicians as ICU antimicrobial stewards. CONCLUSIONS: ID and critical care physicians endorsed their own group for antimicrobial stewardship, but both groups placed high value on ICU transdisciplinary collaborations. Physicians who were more uncomfortable with uncertain diagnoses reported preference for ID physicians to coordinate ICU antimicrobial stewardship; however, physicians who were less uncomfortable with uncertain diagnoses placed greater value on ICU collaborations.

Dipyridamole-associated shock and pulmonary edema.

OBJECTIVE: To report a case of fulminant shock and noncardiogenic pulmonary edema induced by intravenously administered dipyridamole. CASE SUMMARY: A 73-year-old woman presented to the office of her cardiologist for dipyridamole myocardial scintigraphy. Several minutes after administration of intravenous dipyridamole 0.57 mg/kg over 4 minutes she developed wheezing, followed by cardiovascular collapse and pulmonary edema requiring 100% oxygen and endotracheal intubation. She had never received dipyridamole before this, and no other medications or exposures were documented proximate to the collapse. On transfer to the hospital, she developed shock refractory to multiple vasopressors, which responded to continuous infusions of epinephrine. She also had severe pulmonary edema requiring invasive ventilation, 100% inspired oxygen, and 24 cm H2O positive end-expiratory pressure. An echocardiogram did not show new left-ventricular dysfunction and there were signs of right-heart underfilling, supporting a diagnosis of noncardiogenic pulmonary edema. Both shock and pulmonary edema resolved within 12 hours. DISCUSSION: Dipyridamole-associated hypotension has been reported in a number of case series and registries. Detailed case descriptions, however, are not available in the literature to permit understanding of the mechanism of shock following hypotension resulting from dipyridamole myocardial scintigraphy. Our case is exceptional in that echocardiography results support a diagnosis of hypovolemic (rather than cardiogenic) shock. To our knowledge, this is the first case of severe (most likely noncardiogenic) pulmonary edema associated with intravenous infusion of dipyridamole. An objective causality assessment suggested that this patient's cardiopulmonary collapse was probably related to dipyridamole. CONCLUSIONS: While hypotension has been previously associated with intravenous use of dipyridamole, ours is the first report to suggest a noncardiogenic mechanism for shock. To our knowledge, this is the first reported case of noncardiogenic pulmonary edema following dipyridamole infusion.

Building effective critical care teams.

Critical care is formulated and delivered by a team. Accordingly, behavioral scientific principles relevant to teams, namely psychological safety, transactive memory and leadership, apply to critical care teams. Two experts in behavioral sciences review the impact of psychological safety, transactive memory and leadership on medical team outcomes. A clinician then applies those principles to two routine critical care paradigms: daily rounds and resuscitations. Since critical care is a team endeavor, methods to maximize teamwork should be learned and mastered by critical care team members, and especially leaders.

Outcomes of critically ill patients who received cardiopulmonary resuscitation.

RATIONALE: Studies examining survival outcomes after in-hospital cardiopulmonary arrest (CPA) among intensive care unit (ICU) patients requiring medications for hemodynamic support are limited. OBJECTIVES: To examine outcomes of ICU patients who received cardiopulmonary resusitation. METHODS: We identified 49,656 adult patients with a first CPA occurring in an ICU between January 1, 2000 and August 26, 2008 within the National Registry of Cardiopulmonary Resuscitation. Survival outcomes of patients requiring hemodynamic support immediately before CPA were compared with those of patients who did not receive hemodynamic support (pressors), using multivariable logistic regression analyses to adjust for differences in demographics and clinical characteristics. Pressor medications included epinephrine, norepinephrine, phenylephrine, dopamine, dobutamine, and vasopressin. MEASUREMENTS AND MAIN RESULTS: The overall rate of survival to hospital discharge was 15.9%. Patients taking pressors before CPA were less likely to survive to discharge (9.3 vs. 21.2%; P < 0.0001). After multivariable adjustment, patients taking pressors before pulseless CPA were 55% less likely to survive to discharge (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.42-0.48). Age equal to or greater than 65 years (adjusted OR, 0.77; 95% CI, 0.73-0.82), nonwhite race (adjusted OR, 0.58; 95% CI, 0.54-0.62), and mechanical ventilation (adjusted OR, 0.60; 95% CI, 0.56-0.63) were also variables that could be identified before CPA that were independently associated with lower survival. More than half of survivors were discharged to rehabilitation or extended care facilities. Only 3.9% of patients who had CPA despite pressors were discharged home from the hospital, as compared with 8.5% of patients with a CPA and not taking pressors (adjusted OR, 0.53; 95% CI, 0.49-0.59). CONCLUSIONS: Although overall survival of ICU patients was 15.9%, patients requiring pressors and who experienced a CPA in an ICU were half as likely to survive to discharge and to be discharged home than patients not taking pressors. This study provides robust estimates of CPR outcomes of critically ill patients, and may assist clinicians to inform consent for this procedure.

Sustaining Medicare's promise.

Medicare is projected to face shortfalls by 2024. Structural changes of the program have been discussed, but current healthcare reform proposals have not included modifications that are certain to reduce expenditures. One idea that is gaining political traction is to advance the age of beneficiaries to match that of Social Security (ie, 67). This article reviews the rationale and savings associated with this proposal.

Medicaid patients' access to subspecialty care in Connecticut: teaching clinics questionnaire.

OBJECTIVE: To determine whether Medicaid patients have ready access to subspecialty care. METHODS: A survey was administered to training program directors and federal clinic chiefs to ascertain, for each medical and surgical subspecialty, whether their patients had access to care "never, rarely, sometimes, usually, or always." RESULTS: Seventeen respondents indicated that, on average, subspecialty care in Connecticut was available "never, rarely or sometimes," 36% of the time. Results of a smaller national sample, mirrored Connecticut responses. CONCLUSION: Despite government mandates, Medicaid patients have insufficient access to subspecialty care.

Individualized education plans in medical education.

BACKGROUND: Individualized education plans (IEP) are commonly used in nonmedical educational programs to define students' deficiencies and action plans for addressing them. There are no reports of using IEP for medical education. SETTING: Internal medicine residency of a community teaching hospital. METHODS: Residents requiring IEP were identified by a consensus of faculty members. IEPs, overseen by mentors, included: 1. List of deficiencies, 2. Techniques for remediation, 3. Schedule for meetings and re-evaluation of IEP progress. Demographic and evaluative data were abstracted from the performance files of internal medicine residents who served in the program between 2003 and 2010. Characteristics and educational outcomes of those receiving IEPs were compared to those not requiring IEPs. RESULTS: Of 92 residents, 16 received IEPs; 13 for medical knowledge, four for professionalism and one for communication.Average age was greater (35.2 vs 30.3 y; P=0.004) and graduation less recent (8.7 vs 4.8 y; P=0.03). USMLE step I and American Board of Internal Medicine in-service scores were lower in those with IEP (82.6 vs 89.4; P=0.001; 44.6 vs 68.5 percentile relative to same-PGY level; P=0.01). Three residents repeated a PGY year (two successfully) and four completed two to six extra months at the same PGY level. All but two residents in the program between 2003 and 2010 passed Boards on their first attempt; neither had an IEP. Of the 12 with successful IEPs, three graduated to primary-care positions, two to hospitalist positions, and six to subspecialty fellowships; one was lost to follow-up. CONCLUSION: A formal IEP process similar to that employed in nonmedical education was associated with successful graduation and board certification in a majority of medical trainees who required remediation.