A Rare Case of Plastic Bronchitis in an Adult Patient After Cardiopulmonary Bypass.

Plastic bronchitis is a rare life-threatening complication observed after cardiopulmonary bypass (CPB). We describe a case of a 54-year-old man in whom a fulminant case of plastic bronchitis developed after coronary artery bypass grafting (CABG) and mitral valve repair. A brief review of the literature is also presented.

Factors associated with utilization of an inpatient palliative care consultation service in an urban public hospital.

RATIONALE: To evaluate factors associated with palliative care consultation (PCC) in an urban public hospital. METHODS: A retrospective chart review of patients who died on inpatient medical services. RESULTS: Patients with a PCC were more likely to have a "do not resuscitate" (DNR) order at the time of death (p<0.001) and had a decreased likelihood of death in the ICU (p<0.001). Factors associated with PCC in a multivariate analysis included: cancer diagnosis (p=0.01), at least a high school education (p=0.04), older age (p=.003), and birth outside the US (p=0.03). CONCLUSION: The increased PCC utilization for immigrants is in contrast to previously reported literature. This increased use may be because access to services in a municipal hospital is not driven by demographic and socioeconomic factors.

Barriers to end-of-life care in the intensive care unit: perceptions vary by level of training, discipline, and institution.

PURPOSE: Barriers to providing quality end-of-life (EOL) care in the intensive care unit (ICU) are common, but little is known about how these barriers vary by level of training or discipline. METHODS: Medical residents and ICU fellows, attendings, and nurses at two teaching hospitals were surveyed about barriers to EOL care in the ICU. The survey consisted of questions about possible barriers in four domains: patient-family factors, clinician factors, institutional factors, and education-training factors. RESULTS: There were significant differences in reported barriers to EOL care by level of training, discipline, and institution, particularly in the education-training domain. Insufficient resident training in EOL care was reported as a large or huge barrier by a smaller proportion of residents (20%) than attendings (62%), fellows (55%) or nurses (36%) (p=0.001). Nurses' perceptions of barriers to EOL care varied between institutions. Barriers that varied significantly between nurses included difficulty communicating due to language (p=0.008), and inadequate training in recognition of pain and anxiety (p=0.001). CONCLUSIONS: We found that perceived barriers to EOL care differed significantly by level of training, discipline and institution, suggesting the interventions to improve EOL care may need to be locally targeted and specific to level of training and discipline.

Type B lactic acidosis as a severe metabolic complication in lymphoma and leukemia: a case series from a single institution and literature review.

Type B lactic acidosis is a rare complication of hematologic malignancies. The exact mechanism of this process is not well understood. Because caregivers may not be aware of the association of type B lactic acidosis with hematologic malignancies, it may go unrecognized as a cause of acidosis in these patients. We report the cases of 7 patients with type B lactic acidosis who were cared for by members of the Brown Medical School Hematology/Oncology Division. Of the 7 patients reported, 5 had lymphomas and 2 had chronic lymphocytic leukemia. One of the lymphomas was a T-cell lymphoma. Of the patients we were able to evaluate, there did not seem to be a unique cluster of differentiation marker in association with type B lactic acidosis. We also review 14 additional cases, most reported since 2001. From our review of the literature, we suggest that a deficiency of thiamine or riboflavin may play a more pivotal role than previously recognized in the development of type B lactic acidosis associated with malignancy. Further investigation should be undertaken to learn if thiamine or riboflavin replacement might be useful in treating this disorder.

Visiting hours policies in New England intensive care units: strategies for improvement.

OBJECTIVE: Dying patients often feel isolated and alone, and restricted visiting hours in the intensive care unit (ICU) has been shown to increase anxiety and dissatisfaction in both critically ill patients and their families. Unrestricted visiting has been identified as a top-ten need by families of patients in the ICU. Because emotional distress experienced by patients and families may persist well beyond the ICU stay, an open visiting policy, by meeting the needs of patients and families, may improve the quality of end-of-life care in the ICU. This two-part study included a survey to determine the visiting hours policies of New England-area hospital ICUs, and nursing focus groups to describe challenges and barriers that nursing staff working in an open ICU have experienced and to provide solutions that will facilitate implementation of an open visiting hours policy. DESIGN: Two-part study: survey and focus groups. SETTING: ICUs in New England and one medical ICU in a tertiary care hospital. SUBJECTS: Registered nurses employed in medical ICUs. INTERVENTIONS: Adult ICUs in the six New England states were located using a library listing of all regional hospitals. A telephone questionnaire interview was used to ascertain visiting hours policies in each ICU. Six focus-group sessions were conducted with nursing staff who work in an urban, northeastern ICU with 8 yrs of experience with an unrestricted visiting hours policy. MEASUREMENTS AND MAIN RESULTS: A total of 171 hospitals completed the questionnaire (96%). From all ICUs surveyed, 62 (32%) had unrestricted, open visiting hours. Out of these, 57 (92%) were medical ICUs or mixed medical/surgical ICUs. Nursing staff identified three major areas of concern with an open visiting hours policy: space, conflict, and burden. Strategies for resolution that are either employed or advocated by nursing staff are described. CONCLUSIONS: The majority of ICUs in New England have restricted visiting hours. Only one third of ICUs have open visiting policies. Nursing concerns with an unrestricted ICU were identified and solutions were offered that may provide guidance for other ICUs considering adopting an open visiting hours policy.