Simulation-Based Examination of Arterial Line Insertion Method Reveals Interdisciplinary Practice Differences.

INTRODUCTION: Arterial cannulation is frequently performed on intensive care unit (ICU) and operating room patients; a 1% complication rate has been reported. Investigators applied simulation to study clinical providers' arterial catheter (AC) insertion performance and to assess for interdisciplinary and intradisciplinary variation that may contribute to complications. METHODS: Anesthesia, medical critical care, and surgical critical care providers with AC insertion experience were enrolled at 2 academic hospitals. Each subject completed a simulated AC insertion on an in situ task trainer. Using a Delphi-derived checklist that incorporated published recommendations, expert opinion, and institutional requirements, 2 investigators completed offline video reviews to compare subjects' technical performance. RESULTS: Ten anesthesia, 11 medical ICU (MICU, 1 excluded), and 10 surgical ICU (SICU) subjects with significant between-group differences in training level and AC insertion experience were enrolled for 2 years. Differences in procedural planning, equipment preparation, and patient preparation steps did not attain significance across groups except for anesthesia participants using only ad hoc AC kits, and MICU and SICU subjects preferentially using commercial kits (P < 0.001). Time-outs were completed by 1 anesthesia subject, 5 MICU subjects, and 4 SICU subjects (P = 0.29, NS). For proceduralist preparation steps, fewer anesthesiology subjects donned gowns (P < 0.001). Only MICU subjects used ultrasound guidance (P = 0.0053), and only MICU (100%) and SICU (100%) subjects sutured ACs in place. Overall observance of sterile technique was similar across groups at 70% to 100% (P = 0.32). CONCLUSIONS: Simulated AC insertions revealed procedural performance variability that may derive from individual provider differences, discipline-based practice parameters, and setting-specific cultural factors.

Intensive care unit rounding checklists to reduce catheter-associated urinary tract infections.

OBJECTIVE: To assess whether the implementation of an intensive care unit (ICU) rounding checklist reduces the number of catheter-associated urinary tract infections (CAUTIs). DESIGN: Retrospective before-and-after study that took place between March 2013 and February 2017. SETTING: An academic community hospital 16-bed, mixed surgical, cardiac, medical ICU. PATIENTS: Participants were all patients admitted to the adult mixed ICU and had a diagnosis of CAUTI. INTERVENTION: Initiation of an ICU rounding checklist that prompts physicians to address any use of urinary catheters with analysis comparing the preintervention period before roll out of the rounding checklist versus the postintervention periods. RESULTS: There were 19 CAUTIs and 9,288 urinary catheter days (2.04 CAUTIs per 1,000 catheter days). The catheter utilization ratio increased in the first year after the intervention (0.67 vs 0.60; P = .0079), then decreased in the second year after the intervention (0.53 vs 0.60; P = .0992) and in the third year after the intervention (0.53 vs 0.60; P = .0224). The rate of CAUTI (ie, CAUTI per 1,000 urinary catheter days) decreased from 4.62 before the checklist was implemented to 2.12 in the first year after the intervention (P = .2104). The CAUTI rate was 0.45 in the second year (P = .0275) and 0.96 in the third year (P = .0532). CONCLUSIONS: Our study suggests that utilization of a daily rounding checklist is associated with a decrease in the rates of CAUTI in ICU patients. Incorporating a rounding checklist is feasible in the ICU.

Lung Ultrasound for Diagnosing Patients with Severe Dyspnea and Acute Hypoxic Respiratory Failure.

Acute hypoxic respiratory failure can be caused by severe pneumonia, cardiogenic pulmonary edema (CPE), and acute respiratory distress syndrome (ARDS). Differentiating between these causes in critically ill patients can be challenging. Lung ultrasound (LUS) evaluation of acute respiratory failure has been developed and adopted only recently. LUS offers promise as a valuable clinical tool for the diagnosis and treatment of patients with severe dyspnea and acute hypoxic respiratory failure.

The impact of errors on healthcare professionals in the critical care setting.

PURPOSE: Medical errors occur at high rates in intensive care units (ICUs) and have great consequences. The impact of errors on healthcare professionals is rarely discussed. We hypothesized that issues regarding blame and guilt following errors in the ICU exist and may be dependent on type of practitioner, level of experience, and error type. MATERIALS AND METHODS: An online survey was conducted of members of a large critical care medical society addressing three clinical scenarios of procedural, diagnostic and treatment errors. RESULTS: Nine hundred one practitioners responded. In all scenarios, negative feeling after medical errors occurred in all practitioners regardless of experience or field. Surgeons and anesthesiologists showed higher negative responses after procedural errors while internal medicine and emergency medicine practitioners had higher negative responses after diagnostic errors. Survey respondents identified multiple ways to address these adverse feelings, including debriefing with the medical team (68%), talking with colleagues (68%) and discussing with patients and families (36%). CONCLUSIONS: In critical care, blame and guilt after medical errors are common and affect all providers. Critical care practitioners have identified methods which may help mitigate adverse feeling after medical errors, including debriefing and talking with colleagues. Hospitals may benefit from developing these types of strategies after medical errors.

Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients.

PURPOSE: Measurement of inferior vena cava collapsibility (cIVC) by point-of-care ultrasound (POCUS) has been proposed as a viable, non-invasive means of assessing fluid responsiveness. We aimed to determine the ability of cIVC to identify patients who will respond to additional intravenous fluid (IVF) administration among spontaneously breathing critically-ill patients. METHODS: Prospective observational trial of spontaneously breathing critically-ill patients. cIVC was obtained 3cm caudal from the right atrium and IVC junction using POCUS. Fluid responsiveness was defined as a≥10% increase in cardiac index following a 500ml IVF bolus; measured using bioreactance (NICOM™, Cheetah Medical). cIVC was compared with fluid responsiveness and a cIVC optimal value was identified. RESULTS: Of the 124 participants, 49% were fluid responders. cIVC was able to detect fluid responsiveness: AUC=0.84 [0.76, 0.91]. The optimum cutoff point for cIVC was identified as 25% (LR+ 4.56 [2.72, 7.66], LR- 0.16 [0.08, 0.31]). A cIVC of 25% produced a lower misclassification rate (16.1%) for determining fluid responsiveness than the previous suggested cutoff values of 40% (34.7%). CONCLUSION: IVC collapsibility, as measured by POCUS, performs well in distinguishing fluid responders from non-responders, and may be used to guide IVF resuscitation among spontaneously breathing critically-ill patients.

Arterial Catheter Use in the ICU: A National Survey of Antiseptic Technique and Perceived Infectious Risk.

OBJECTIVES: Recent studies have shown that the occurrence rate of bloodstream infections associated with arterial catheters is 0.9-3.4/1,000 catheter-days, which is comparable to that of central venous catheters. In 2011, the Centers for Disease Control and Prevention published new guidelines recommending the use of limited barrier precautions during arterial catheter insertion, consisting of sterile gloves, a surgical cap, a surgical mask, and a small sterile drape. The goal of this study was to assess the attitudes and current infection prevention practices used by clinicians during insertion of arterial catheters in ICUs in the United States. DESIGN: An anonymous, 22-question web-based survey of infection prevention practices during arterial catheter insertion. SETTING: Clinician members of the Society of Critical Care Medicine. SUBJECTS: Eleven thousand three hundred sixty-one physicians, nurse practitioners, physician assistants, respiratory therapists, and registered nurses who elect to receive e-mails from the Society of Critical Care Medicine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1,265 responses (11% response rate), with 1,029 eligible participants after exclusions were applied. Only 44% of participants reported using the Centers for Disease Control and Prevention-recommended barrier precautions during arterial catheter insertion, and only 15% reported using full barrier precautions. The mean and median estimates of the incidence density of bloodstream infections associated with arterial catheters were 0.3/1,000 catheter-days and 0.1/1,000 catheter-days, respectively. Thirty-nine percent of participants reported that they would support mandatory use of full barrier precautions during arterial catheter insertion. CONCLUSIONS: Barrier precautions are used inconsistently by critical care clinicians during arterial catheter insertion in the ICU setting. Less than half of clinicians surveyed were in compliance with current Centers for Disease Control and Prevention guidelines. Clinicians significantly underestimated the infectious risk posed by arterial catheters, and support for mandatory use of full barrier precautions was low. Further studies are warranted to determine the optimal preventive strategies for reducing bloodstream infections associated with arterial catheters.

Combination therapy for the treatment of pulmonary arterial hypertension.

Multiple medical therapies have been developed for the treatment of pulmonary arterial hypertension (PAH) over the last decade and a half. Unfortunately, none of these medications is curative and the majority of patients develop disease progression despite treatment. Presently available medications target one of three known pathways that have been implicated in disease pathogenesis. The multiplicity of pulmonary vascular abnormalities identified in PAH provides the rationale for a therapeutic strategy that targets more than one mechanism at a time. Although a handful of studies have demonstrated clinical improvement in PAH patients who have a second medication added to stable background therapy in a randomized, placebo-controlled fashion, it is unclear whether the derived benefit is due to the combination of two therapies or merely the response to the new agent. This review discusses the rationale for combination therapy, critically reviews the findings of presently completed combination studies and outlines the need for new studies that are better designed to determine whether combination therapy is more efficacious than single agent therapies for the treatment of PAH.

Reducing mortality in severe sepsis and septic shock.

Severe sepsis is one of the most common reasons for critically ill patients to be admitted to an intensive care unit (ICU) and has very high associated morbidity and mortality. The Surviving Sepsis Campaign was initiated with the hope that mortality might be reduced by standardizing care informed by data from an increasing number of clinical trials. Important methods for reducing mortality identified by recent studies include aggressive fluid resuscitation, early goal-directed therapy (EGDT), early administration of antibiotics, and the administration of activated protein C to eligible patients.