Healthcare systems are large contributors to global emissions, and intensive care units (ICUs) are a complex and resource-intensive component of these systems. Recent global movements in sustainability initiatives, led mostly by Europe and Oceania, have tried to mitigate ICUs' notable environmental impact with varying success. However, there exists a significant gap in the U.S. knowledge and published literature related to sustainability in the ICU. After a narrative review of the literature and related industry standards, we share our experience with a Green ICU initiative at a large hospital system in Texas. Our process has led to a 3-step pathway to inform similar initiatives for sustainable (green) critical care. This pathway involves (1) establishing a baseline by quantifying the status quo carbon footprint of the affected ICU as well as the cumulative footprint of all the ICUs in the healthcare system; (2) forming alliances and partnerships to target each major source of these pollutants and implement specific intervention programs that reduce the ICU-related greenhouse gas emissions and solid waste; and (3) finally to implement a systemwide Green ICU which requires the creation of multiple parallel pathways that marshal the resources at the grass-roots level to engage the ICU staff and institutionalize a mindset that recognizes and respects the impact of ICU functions on our environment. It is expected that such a systems-based multi-stakeholder approach would pave the way for improved sustainability in critical care.
Intensive Care Units , Humans , Intensive Care Units/organization & administration , Intensive Care Units/trends , Critical Care/methods , Critical Care/trends , Sustainable Development/trends , Carbon Footprint , Hospitals/trends , Hospitals/standards , Texas
Driving pressure (∆P) is a core therapeutic component of mechanical ventilation (MV). Varying levels of ∆P have been employed during MV depending on the type of underlying pathology and severity of injury. However, ∆P levels have also been shown to closely impact hard endpoints such as mortality. Considering this, conducting an in-depth review of ∆P as a unique, outcome-impacting therapeutic modality is extremely important. There is a need to understand the subtleties involved in making sure ∆P levels are optimized to enhance outcomes and minimize harm. We performed this narrative review to further explore the various uses of ∆P, the different parameters that can affect its use, and how outcomes vary in different patient populations at different pressure levels. To better utilize ∆P in MV-requiring patients, additional large-scale clinical studies are needed.
BACKGROUND: Workplace violence (WPV) is a global problem that affects healthcare workers' physical and mental health and impairs work performance. Pakistan's healthcare system is not immune to WPV, which the World Health Organization recognises as an occupational hazard. OBJECTIVES: The primary objective of this systematic review is to determine the prevalence of physical, verbal, or other forms of WPV in healthcare workers in Pakistan. Secondary objectives include identifying the associated risk factors and perpetrators of WPV. METHODS: A systematic review of six electronic databases was conducted through August 2022. Studies were included if they met the following criteria: 1) healthcare workers (HCWs), including physicians, nurses, and paramedic staff working in the private or public sector of Pakistan; 2) exposure to physical, verbal, or any type of violence. Data were extracted and analysed for the prevalence of WPV, types of violence, associated risk factors, and perpetrators of violence. RESULTS: Twenty-four studies including 16,070 HCWs were included in this review. Verbal violence was the most common form of violence levied, with its highest prevalence (100%) reported in Islamabad and lowest verbal violence prevalence (25%) in Karachi. Verbal abuse was preponderant against female HCWs, while physical abuse was directed more towards males. The most common perpetrators were patient attendants, followed by the patients. CONCLUSION: Our review determines a 25-100% prevalence of WPV against HCWs in Pakistani medical setups. This occupational hazard needs the attention of relevant authorities in the country to put protective enforcement policies in place. Large-scale surveys should be conducted to better gauge the current plight of HCWs in the nation.
Physicians , Workplace Violence , Male , Humans , Female , Pakistan/epidemiology , Health Personnel , Allied Health Personnel
Vasoplegia is a condition characterized by persistent low systemic vascular resistance despite a normal or high cardiac index, resulting in profound and uncontrolled vasodilation. Vasoplegia may occur due to various conditions, including cardiac failure, sepsis, and post-cardiac surgery. In the cardiac cohort, multiple risk factors for vasoplegia have been identified. Several factors contribute to the pathophysiology of this condition, and various mechanisms have been proposed, including nitric oxide, adenosine, prostanoids, endothelins, the renin-angiotensin-aldosterone system, and hydrogen sulfide. Early identification and prompt management of vasoplegia is crucial to prevent development of shock. This review expands upon the different vasopressors used in management of vasoplegia, including catecholamines such as norepinephrine, dopamine, epinephrine, phenylephrine, and other agents including vasopressin, methylene blue, angiotensin II, hydroxocobalamin, vitamin C, thiamine, and corticosteroids (ie, hydrocortisone). It also emphasizes the importance of conducting further research and making advancements in treatment regimens for vasoplegia.
Sepsis , Vasoplegia , Humans , Vasoplegia/diagnosis , Vasoplegia/drug therapy , Vasoplegia/etiology , Epinephrine , Norepinephrine , Phenylephrine
Evidence-based medicine (EBM) is the use of high-quality clinical research in making decisions about the care of patients. Its formal origin dates back to the mid-nineteenth century, and since then, it has continued to evolve. The best research evidence, clinical expertise, and patient values are described as the foundations of EBM. However, several tools and skills have been developed and added over time. EBM has faced a lot of criticism, and the pitfalls are widely discussed and published in the medical literature. The biggest challenge is the changing paradigm of healthcare, cost-effectiveness, and changing evidence which has led to controversies and challenges in the rapid adaptation of the EBM. This review article discusses the history, conception, and evolution of modern-day EBM. In addition, we discuss why EBM has been criticized and highlight the pitfalls.
Thrombolytic therapy has been the mainstay for patients with pulmonary embolism (PE). Despite being linked to a higher risk of significant bleeding, clinical trials demonstrate that thrombolytic therapy should be used in patients with moderate to high-risk PE, in addition to hemodynamic instability symptoms. This prevents the progression of right heart failure and impending hemodynamic collapse. Diagnosing PE can be challenging due to the variety of presentations; therefore, guidelines and scoring systems have been established to guide physicians to correctly identify and manage the condition. Traditionally, systemic thrombolysis has been utilized to lyse the emboli in PE. However, newer techniques for thrombolysis have been developed, such as endovascular ultrasound-assisted catheter-directed thrombolysis for massive and intermediate-high submassive risk groups. Additional newer techniques explored are the use of extracorporeal membrane oxygenation, direct aspiration, or fragmentation with aspiration. Because of the constantly changing therapeutic options and the scarcity of randomized controlled trials, choosing the best course of treatment for a given patient may be difficult. To help, the Pulmonary Embolism Reaction Team is a multidisciplinary, rapid response team that has been developed and is used at many institutions. Hence to bridge the knowledge gap, our review highlights various indications of thrombolysis in addition to the recent advances and management guidelines.
Intracardiac thrombus is often seen as a complication of ischemic heart disease (IHD) and non-ischemia cardiomyopathies (NICM). The advancements in imaging modalities and therapeutic options have helped reduce the complications arising from ventricular thrombi, such as systemic embolization. Here we present two cases of intracardiac thrombus associated with coronavirus disease (COVID) 19, one with an apical thrombus in the left ventricle and the other with a thrombus in the right ventricle adjacent to chordae tendinae. The effects of covid-19 on the cardiovascular system are yet to be thoroughly evaluated. Venous and arterial thrombosis is commonly associated with COVID-19 but in situ detection of intracardiac thrombus has not been very frequently reported. Intracardiac thrombus and embolization pose a very high risk of complications in COVID-19. The coronavirus pandemic caused by SARS-CoV-2 during 2019-2021 has caused several deaths and has resulted in many long-term consequences, many of which remain unclear. In-hospital complications from COVID-19 are better reported due to constant monitoring. The ongoing, late, and chronic complications arising from COVID-19 require more vigilant case-by-case screening and surveillance.
The emergence of SARS-CoV-2 in late December 2019 has taken the world by storm. In March 2020, the World Health Organization (WHO) named this virus COVID-19. To date, it has infected approximately 186 million people worldwide and is attributed as the cause of death of more than 5 million people (and this number is only increasing.) The global effort to develop vaccines and therapeutics occurred at the fastest pace yet, with several vaccines' approval under emergency authorization use. There are also several post-marketing side effects, including myocarditis, cerebral venous embolism, and Guillain Barre Syndrome. Global vaccine disparity complicates the control of pandemic challenges. Several highly infectious variants have emerged, and more variants are feared to emerge if global vaccination plans are not developed soon.
A paradigm shift towards enhanced strategies to effectively engage patients and families in delivering safe and high-quality healthcare services was observed during recent times, particularly in the last decade. Immediately prior to the coronavirus disease 2019 (Covid-19) pandemic, the tri-institutional global healthcare quality reports from the National Academies of Sciences, Engineering, and Medicine, World Bank Group, and Lancet Global Health Commission reported the patient and family engagement measures used globally, highlighting the variations across the regions of the world. Through a pandemic for more than a year now, we aim to present the key lessons learned from practices and strategies to proactively engage patients and families. These strategies may continue to be implemented in the post-Covid-19 pandemic era to improve patient and family-centered care.
The first leadership emerged simultaneously at the time when humans started forming groups to fight against a common threat or to attain means of survival for food, shelter, and safety. Authors have tried to define, understand, and apply the context of leadership in different social, cultural, political, organizational, and religious setups. This article will describe three aspects of leadership to encompass comprehensive traits of strong leadership in a particular reference to any multidisciplinary intensive care units (ICUs) in a tertiary care hospital.
Lazarus phenomenon refers to autoresuscitation of a patient declared dead after cessation of cardiopulmonary resuscitation (CPR). The Lazarus phenomenon is rarely encountered and pathophysiology is not very well understood, but physicians need to be aware of this phenomenon. It is prudent that a physician leading a CPR effort waits for some time and monitors the patient further using blood pressure and electrocardiogram before confirming that a patient is actually dead.
There is a misconception that urinary incontinence (UI) in older adults, usually above the age of 65 is a part of aging. More than 50% of residents in long-term care (LTC) settings are affected by UI and it is associated in many cases with markedly reduced quality of life. It has become evident that incontinence can be cured or successfully managed. However, many nurses lack sufficient knowledge to intervene appropriately. The purpose of this review is to share how the collaborative efforts of nurses at all levels may lead to increased assessment and interventions of UI in this population.
Education has continued to evolve since the existence of mankind. We have now become more well-equipped and refined our teaching methodology over time. Despite all the progress made, we still continue to rely on bedside huddle for teaching. Globalization has facilitated learning in culturally diverse environment. Grand rounds, noon lectures and conferences help the millennial house-staff to effectively translate their concepts to hands-on clinical experience. Useful teaching strategies like story-telling, connecting, simplifying, playing hierarchy make learning more fun and engaging. Multidisciplinary collaborative learning has eased conceptualization and retention of practical knowledge. Our education system now focuses more on patient-centered, case-based learning system.
After its origin in Wuhan, China, coronavirus related respiratory illness spread across the globe, being declared as a pandemic by WHO on March 13, 2020. Because it is acquired via respiratory droplets, community spread is responsible for the recent global crisis. The current diagnostic options include real-time polymerase chain reaction (RT-PCR) and a few serology tests, including but not limited to the recently approved five minutes serology tests. The disease presents as a lower respiratory tract illness. Anecdotal experiences have shown that imaging characteristics are crucial to diagnosis as radiological evidence of disease appears prior to clinical manifestations and tends to evolve over time, which can be useful in predicting the stage of the disease. CT scan is more sensitive than a chest X-ray in highlighting these changes.
Cardiogenic shock (CS) is a multifactorial disease process with high morbidity and mortality. When it occurs in a peri- or intraoperative setting, factors such as surgery, anesthesia, and post-surgical physiology can negatively affect patient outcomes. Since patient needs often escalate during CS-from medications to mechanical support to palliative care-this disease demands a multidisciplinary approach that encompasses all aspects of medical delivery. Preliminary studies have indicated that a multidisciplinary team approach to CS results in earlier diagnosis and treatment and improves patient outcomes. Here we discuss various management strategies for CS from an anesthesiology, surgery, and critical care perspective.
Delivery of Health Care, Integrated/organization & administration , Patient Care Team/organization & administration , Perioperative Care , Shock, Cardiogenic/therapy , Surgical Procedures, Operative/adverse effects , Anesthesiologists/organization & administration , Cardiologists/organization & administration , Combined Modality Therapy , Early Diagnosis , Humans , Monitoring, Intraoperative , Perioperative Period , Predictive Value of Tests , Recovery of Function , Risk Factors , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/etiology , Shock, Cardiogenic/physiopathology , Surgeons/organization & administration , Treatment Outcome
The global healthcare delivery paradigm shift calls for enhanced strategies to engage patients in delivering safer and high-quality healthcare. There still exists a gap area in a globally accepted measure for the person-centered care. Recent tri-institutional global quality reports from National Academies of Sciences, Engineering, and Medicine (NAESM), World Bank Group, and Lancet Global Health Commission attempted to report the patient engagement measures used globally. We aim to understand the variation in these globally reported patient-centered care measures and highlight the recent proactive strategies to enhance patient engagement to improve patient safety. I.
Emergent Transcatheter Aortic Valve Replacement (TAVR) is a strategy that has been used for management of severely decompensated patients who are unlikely to tolerate an open procedure (Kolte et al., 2018). Recently, in the context of degenerated valve bioprosthesis, valve-in-valve (ViV) transcatheter aortic valve replacement has become an acceptable management strategy (Kalra et al., 2019 [2]). Here, we present this rare case of a 25-year-old, post-partum female with DiGeorge Syndrome, who presented with severe bioprosthetic valve stenosis leading to heart failure. She initially had received a biologic valve in order to have children; however, following delivery of her child, she developed valve failure that was severe enough to preclude her from receiving a surgical aortic valve replacement. ViV TAVR was performed emergently to improve heart failure and bridge the time to definitive treatment, when she would be able to safely receive a mechanical valve. After valve placement, echocardiogram showed no evidence of aortic regurgitation or paravalvular leak with a mean gradient of 2 mmHg, and she was ultimately discharged. Our patient was recovering well at her two-month follow up appointment. This case highlights the need for further research in the use of ViV TAVR in younger patient populations in emergent situations.
Bioprosthesis , DiGeorge Syndrome , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Transcatheter Aortic Valve Replacement , Adult , Aortic Valve/surgery , Aortic Valve Stenosis/surgery , Female , Humans , Prosthesis Design , Prosthesis Failure , Treatment Outcome
BACKGROUND: Prolonged Mechanical Ventilation (PMV) is associated with a higher cost of care and increased morbidity and mortality. Patients requiring PMV are referred mostly to Long-Term Acute Care (LTAC) facilities. OBJECTIVE: To determine if protocol-driven weaning from mechanical ventilator by Respiratory Therapist (RT) would result in quicker weaning from mechanical ventilation, cost-effectiveness, and decreased mortality. METHODS: A retrospective case-control study was conducted that utilized protocol-driven ventilator weaning by respiratory therapist (RT) as a part of the Respiratory Disease Certification Program (RDCP). RESULTS: 51 patients on mechanical ventilation before initiation of protocol-based ventilator weaning formed the control group. 111 patients on mechanical ventilation after implementation of the protocol formed the study group. Time to wean from the mechanical ventilation before the implementation of protocol-driven weaning by RT was 16.76 +/- 18.91 days, while that after the implementation of protocol was 7.67 +/- 6.58 days (p < 0.0001). Mortality proportion in patients after implementation of protocol-based ventilator weaning was 0.21 as compared to 0.37 in the control group (p=0.0153). The daily cost of patient care for the LTAC while on mechanical ventilation was $2200/day per patient while it was $ 1400/day per patient while not on mechanical ventilation leading to significant cost savings. CONCLUSION: Protocol-driven liberation from mechanical ventilation in LTAC by RT can significantly decrease the duration of a mechanical ventilator, leading to decreased mortality and cost savings.
Pneumoperitoneum is pneumatosis in the potential space of the abdominal cavity. It is generally considered a surgical emergency and is mostly due to perforated hollow viscus. Rarely, pneumoperitoneum might occur even in the absence of bowel perforation. We hereby present a case of pneumoperitoneum in a patient with COVID-19 pneumonia and pneumomediastinum, which was managed non-surgically.
BACKGROUND: There is mixed evidence in the superiority of conservative versus conventional approach to oxygen therapy among patients admitted into the intensive care unit (ICU). The purpose of this study was to determine if conservative versus conventional oxygenation results in a statistically significant difference in outcomes in ICU patients. METHODS: A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria consisted of Level I-IV investigations of conservative versus conventional oxygenation among ICU patients. ICU mortality, 28-day mortality, in-hospital mortality, ICU length-of-stay, hospital length-of-stay, rate of new infections, and rate of new non-respiratory organ failure were compared using two-sample Z-tests using p-value less than 0.05. RESULTS: Three thousand four hundred thirty-three articles were screened. Four articles were included in the analysis. Three hundred seventy-two patients under the conservative oxygenation arm (Minimum target SpO2: 88-94%) and 370 patients under the conventional oxygenation arm (Minimum target SpO2: 96-97%) were analyzed. ICU mortality (16.7 ± 9.5% vs. 22.7 ± 6.0%; P<0.01), 28-day mortality (34.6 ± 26.4% vs. 41.6 ± 14.6%; P=0.02), and in-hospital mortality (30.2 ± 22.5% vs. 37.7 ± 14.2%; P<0.01) were all significantly lower in the conservative oxygenation arm versus the conventional oxygenation arm, respectively. Rate of new non-respiratory organ failure was also significantly lower in the conservative oxygenation arm (20.0 ± 8.5% vs. 29.7 ± 11.7%; P<0.01). CONCLUSION: The authors conclude that conservative oxygenation therapy could result in significantly lower rates of ICU mortality, 28-day mortality, in-hospital mortality, and new-onset non-respiratory organ failure. Further randomized controlled studies that show clinical outcome improvement in multiple parameters may be worthwhile to assess the true efficacy of this practice.
