Patient-Centered Care and Autonomy: Shared Decision-Making in Practice and a Suggestion for Practical Application in the Critically Ill.

Decision-making for the hospitalized dying and critically ill is often characterized by an understanding of autonomy that leads to clinical care and outcomes that are antithetical to patients' preferences around suffering and quality of life. A better understanding of autonomy will facilitate the ultimate goal of a patient-centered approach and ensure compassionate, high-quality care that respects our patients' values. We reviewed the medical literature and our experiences through the ethics service, palliative care service, and critical care service of a large community teaching hospital. The cumulative experience of a senior intensivist was filtered through the lens of a medical ethicist and the palliative care team. The practical application of patient-centered care was discerned from these interactions. We determined that a clearer understanding of patient-centeredness would improve the experience and outcomes of care for our patients as well as our adherence to ethical practice. The practical applications of autonomy and patient-centered care were evaluated by the authors through clinical interactions on the wards to ascertain problems in understanding their meaning. Clarification of autonomy and patient-centeredness is provided using specific examples to enhance understanding and application of these principles in patient-centered care.

Tissue Edema, Fluid Balance, and Patient Outcomes in Severe Sepsis: An Organ Systems Review.

Severe sepsis and septic shock remain among the deadliest diseases managed in the intensive care unit. Fluid resuscitation has been a mainstay of early treatment, but the deleterious effects of excessive fluid administration leading to tissue edema are becoming clearer. A positive fluid balance at 72 hours is associated with significantly increased mortality, yet ongoing fluid administration beyond a durable increase in cardiac output is common. We review the pathophysiologic and clinical data showing the negative effects of edema on pulmonary, renal, central nervous, hepatic, and cardiovascular systems. We discuss data showing increased morbidity and mortality following nonjudicious fluid administration and challenge the assumption that patients who are fluid responsive are also likely to benefit from that fluid. The distinctions between fluid requirement, responsiveness, and tolerance are central to newer concepts of resuscitation. We summarize data in each organ system showing a predictable increase in morbidity and mortality with nonbeneficial fluid administration, providing a better framework for precision in volume management of the patient with severe sepsis.

The dangers of extreme body mass index values in patients with Clostridium difficile.

PURPOSE: To examine the association between body mass index (BMI) and in-hospital mortality in patients presenting with Clostridium difficile infections in emergency department visits (ED) in the USA. Infected patients with extreme BMIs may have an elevated mortality risk, but prior studies examining this question have been too small to reach definitive conclusions. METHODS: Data were from the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality during 2012. NEDS records emergency department (ED) visits across the USA and provides statistical sampling weights to approximate a nationally representative sample of US hospital-based EDs. Inclusion criteria were adults age 18 or older with an ICD-9 code for C. difficile infection (008.45) and a documented body mass index ICD-9 V code (V85.x). Logistic regression was used to predict mortality after adjusting for demographic variables and chronic comorbidities defined by Elixhauser. RESULTS: A weighted sample of 22,937 ED visits met all inclusion criteria. The cohort's mean age was 66. 64.6% were female. The unadjusted mortality rate was 6.5%. Patients with a BMI < 19 kg/m2 had an adjusted odds ratio of 2.73; 95% CI (1.80, 4.16), p < 0.001 compared to patients with a BMI of 19.0-4.9 kg/m2 (the referent category). In obese patients, only BMI values >40 kg/m2 were associated with significantly greater mortality risk. CONCLUSION: Being underweight (BMI < 19) or morbidly obese (BMI > 40) was associated with increased risk of in-hospital mortality in patients presenting with C. difficile infections.

Effects of body surface area-indexed calculations in the morbidly obese: a mathematical analysis.

OBJECTIVE: Cardiac and stroke indices routinely are used to communicate the adequacy of circulation, especially by cardiac anesthesiologists. However, indexed values may be distorted when derived using conventional formulae on morbidly obese patients. In extreme cases, distortion of the raw value by the indexed value may suggest inappropriate therapeutic interventions. This study attempted to highlight threshold values of body surface area (BSA) that place morbidly obese patients at risk of being overtreated. DESIGN: Mathematical analysis. PARTICIPANTS: Simulated patients. INTERVENTIONS: BSA was derived using the commonly used Mosteller and Dubois and Dubois formulae on a range of simulated patients. These simulated BSAs then were applied to normal cardiac output (CO) and stroke volume (SV) values to identify the threshold at which BSA-indexed values result in a change in classification to abnormal. Additionally, the effects of 7 different published BSA formulae were examined, using a range of height-weight combinations. MEASUREMENTS AND MAIN RESULTS: Critical thresholds at which BSA calculations would classify normal CO and SV as abnormal are presented in a tabular form. Among the 7 BSA formulae, there was substantial variation in predicted BSA at a given height-weight combination when values typically associated with morbid obesity are used. CONCLUSION: In morbidly obese patients, cardiac and stroke indices can be misleading relative to the underlying raw values (CO and SV) as a result of distortion by widely used BSA formulae. The authors caution against relying on threshold cardiac and stroke indices as triggers for the initiation of hemodynamic therapies in the morbidly obese. Further research on what BSA formula should be used on patients with very extreme body types is warranted.

Linezolid in methicillin-resistant Staphylococcus aureus nosocomial pneumonia: a randomized, controlled study.

BACKGROUND: Post hoc analyses of clinical trial data suggested that linezolid may be more effective than vancomycin for treatment of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial pneumonia. This study prospectively assessed efficacy and safety of linezolid, compared with a dose-optimized vancomycin regimen, for treatment of MRSA nosocomial pneumonia. METHODS: This was a prospective, double-blind, controlled, multicenter trial involving hospitalized adult patients with hospital-acquired or healthcare-associated MRSA pneumonia. Patients were randomized to receive intravenous linezolid (600 mg every 12 hours) or vancomycin (15 mg/kg every 12 hours) for 7-14 days. Vancomycin dose was adjusted on the basis of trough levels. The primary end point was clinical outcome at end of study (EOS) in evaluable per-protocol (PP) patients. Prespecified secondary end points included response in the modified intent-to-treat (mITT) population at end of treatment (EOT) and EOS and microbiologic response in the PP and mITT populations at EOT and EOS. Survival and safety were also evaluated. RESULTS: Of 1184 patients treated, 448 (linezolid, n = 224; vancomycin, n = 224) were included in the mITT and 348 (linezolid, n = 172; vancomycin, n = 176) in the PP population. In the PP population, 95 (57.6%) of 165 linezolid-treated patients and 81 (46.6%) of 174 vancomycin-treated patients achieved clinical success at EOS (95% confidence interval for difference, 0.5%-21.6%; P = .042). All-cause 60-day mortality was similar (linezolid, 15.7%; vancomycin, 17.0%), as was incidence of adverse events. Nephrotoxicity occurred more frequently with vancomycin (18.2%; linezolid, 8.4%). CONCLUSIONS: For the treatment of MRSA nosocomial pneumonia, clinical response at EOS in the PP population was significantly higher with linezolid than with vancomycin, although 60-day mortality was similar.

Importance of intravenous fluid dose and composition in surgical ICU patients.

PURPOSE OF REVIEW: This review discusses the importance of intravenous fluid dose and composition in surgical ICU patients. On the basis of updated physiologic postulates, we suggest guidelines for the use of crystalloids and colloids. Goal-directed fluid therapy is advocated as a means for avoiding both hypovolemia and hypervolemia. RECENT FINDINGS: Integrity of the endothelial surface layer (ESL) and 'volume context' are key determinants of fluid disposition. During critical illness the ESL is compromised. Optimal resuscitation may be guided by functional measures of fluid responsiveness with some caveats. The best approach may be to use physiologically balanced crystalloids for hypovolemic resuscitation and colloids for euvolemic hemodynamic augmentation. SUMMARY: The routine replacement of unmeasured presumed fluid deficits is not appropriate. In critically ill patients, resuscitation with intravenous fluids should produce a demonstrable enhancement of perfusion. Individualized goal-directed therapy using functional hemodynamic parameters can optimize resuscitation and 'deresuscitation'.

Safe placement of central venous catheters: a measured approach.

INTRODUCTION: To develop a simple method for safely placing central venous catheters (CVCs) outside the heart from the subclavian or internal jugular vein in compliance with Food and Drug Administration (FDA) and manufacturer guidelines. METHODS: Patients requiring CVCs were enrolled into this prospective trial. Central venous catheters were inserted into the subclavian or internal jugular vein from either the right or left side to a depth of 15 cm. Chest radiographs were obtained immediately after insertion of the catheter to check tip placement and to evaluate for mechanical complications. RESULTS: Operators successfully placed 201 of 210 (96%) CVCs outside the heart. Six of these required repositioning. Nine catheter tips were located in an intracardiac position. No cases of pneumothorax, hemothorax, or pericardial tamponade occurred. One case of delayed hydrothorax due to superior vena cava injury occurred. CONCLUSIONS: Using a 15-cm insertion depth via the internal jugular or subclavian vein results in safe catheter tip location in the majority of procedures consistent with FDA and manufacturer guidelines.

Ventilator autocycling and delayed recognition of brain death.

BACKGROUND: Improvements in technology play an important role in caring for critically ill patients. One example is the advance in ventilator design to facilitate triggering of mechanical breaths. Minimal changes in circuit flow unrelated to respiratory effort can trigger a ventilator breath and may mislead caregivers in recognizing brain death. METHODS: We observed patients with devastating brain injuries in a mixed medical/surgical intensive care unit (ICU) with a high clinical suspicion for brain death including the absence of cranial nerve function with apparent spontaneous breathing during patient-triggered modes of mechanical ventilation. Further clinical observation for spontaneous respirations was assessed upon removal of ventilatory support. RESULTS: Nine patients with brain injury due to multiple etiologies were identified and demonstrated no spontaneous respirations when formally assessed for apnea. Length of time between brain death and its recognition could not be determined. CONCLUSION: When brain-dead patients who are suitable organ donors are mistakenly identified as having cerebral activity, the diagnosis of brain death is delayed. This delay impacts resource utilization, impedes recovery and function of organs for donation, and adversely affects donor families, potential recipients of organs, and patient donors who may have testing and treatment that cannot be beneficial. Patients with catastrophic brain injury and absent cranial nerve function should undergo immediate formal apnea testing.

Mitigating exhalation puffs during oxygen therapy for respiratory disease.

We investigate the dispersal of exhalations corresponding to a patient experiencing shortness of breath while being treated for a respiratory disease with oxygen therapy. Respiration through a nasal cannula and a simple O2 mask is studied using a supine manikin equipped with a controllable mechanical lung by measuring aerosol density and flow with direct imaging. Exhalation puffs are observed to travel 0.35 ± 0.02 m upward while wearing a nasal cannula, and 0.29 ± 0.02 m laterally through a simple O2 mask, posing a higher direct exposure risk to caregivers. The aerosol-laden air flows were found to concentrate in narrow conical regions through both devices at several times their concentration level compared with a uniform spreading at the same distance. We test a mitigation strategy by placing a surgical mask loosely over the tested devices. The mask is demonstrated to alleviate exposure by deflecting the exhalations from being launched directly above a supine patient. The surgical mask is found to essentially eliminate the concentrated aerosol regions above the patient over the entire oxygenation rates used in treatment in both devices.

A simple physiologic algorithm for managing hemodynamics using stroke volume and stroke volume variation: physiologic optimization program.

Intravascular volume status and volume responsiveness continue to be important questions for the management of critically ill or injured patients. Goal-directed hemodynamic therapy has been shown to be of benefit to patients with severe sepsis and septic shock, acute lung injury and adult respiratory distress syndrome, and for surgical patients in the operating room. Static measures of fluid status, central venous pressure (CVP), and pulmonary artery occlusion pressure (PAOP) are not useful in predicting volume responsiveness. Stroke volume variation and pulse pressure variation related to changes in stroke volume during positive pressure ventilation predict fluid responsiveness and represent an evolving practice for volume management in the intensive care unit (ICU) or operating room. Adoption of dynamic parameters for volume management has been inconsistent. This manuscript reviews some of the basic physiology regarding the use of stroke volume variation to predict fluid responsiveness in the ICU and operating room. A management algorithm using this physiology is proposed for the critically ill or injured in various settings.

Pressure Injuries at Intensive Care Unit Admission as a Prognostic Indicator of Patient Outcomes.

BACKGROUND: Pressure injuries, also known as pressure ulcers, are a serious complication of immobility. Patients should be thoroughly examined for pressure injuries when admitted to the intensive care unit to optimize treatment. Whether community-acquired pressure injuries correlate with poor hospital outcomes among critically ill patients is understudied. OBJECTIVES: To determine whether pressure injuries present upon admission to the intensive care unit can serve as a predictive marker for longer hospitalization and increased mortality. METHODS: This study retrospectively analyzed admissions of adult patients to a 24-bed medical-surgical intensive care unit in a large level I trauma center in the northeast United States from 2010 to 2012. The association of pressure injuries with mortality and length of stay was assessed, using multivariable logistic regression and generalized linear models, adjusted for age, comorbidities, Acute Physiology and Chronic Health Evaluation III score, and other patient characteristics. RESULTS: Among 2723 patients, 180 (6.6%) had a pressure injury at admission. Patients with a pressure injury had longer mean unadjusted stay (15.6 vs 10.5 days; P < .001) and higher in-hospital mortality rate (32.2% vs 18.3%; P < .001) than did patients without a pressure injury at admission. After multivariable adjustment, pressure injuries were associated with a mean increase in length of stay of 3.1 days (95% CI 1.5-4.7; P < .001). Pressure injuries were not associated with mortality after adjusting for the Acute Physiology and Chronic Health Evaluation III score, but they may serve as a marker for increased risk of mortality if an Acute Physiology and Chronic Health Evaluation III score is unavailable. CONCLUSION: Pressure injuries present at admission to the intensive care unit are an objective, easy-to-identify finding associated with longer stays. Pressure injuries might have a modest association with higher risk of mortality.