Ultrasound-guided Axillary Artery Catheter Placement and Associated Complications in Critically Ill Patients.

BACKGROUND: Arterial catheter placement for hemodynamic monitoring is commonly performed in critically ill patients. The radial and femoral arteries are the two sites most frequently used; there is limited data on the use of the axillary artery for this purpose. The aim of this study was to investigate the rate of complications from ultrasound-guided axillary artery catheter placement in critically ill patients. METHODS: A retrospective study at a tertiary care center of patients admitted to an intensive care unit who had ultrasound-guided axillary artery catheter placement during admission. Primary outcome of interest was catheter related complications, including bleeding, vascular complications, compartment syndrome, stroke or air embolism, catheter malfunction, and need for surgical intervention. RESULTS: This study identified 88 patients who had an ultrasound-guided axillary artery catheter placed during their admission. Of these 88, nine patients required multiple catheters placed, for a total of 99 axillary artery catheter placement events. The median age was 64 [IQR 48, 71], 41 (47%) were female, and median body mass index (BMI) was 26 [IQR 22, 30]. The most common complication was minor bleeding (11%), followed by catheter malfunction (2%), and vascular complications (2%). Univariate analyses did not show any association between demographics and clinical variables, and complications related to axillary arterial catheter. CONCLUSION: The most common complication found with ultrasound-guided axillary artery catheter placement was minor bleeding, followed by catheter malfunction, and vascular complications. Ultrasound-guided axillary arterial catheters are an alternative in patients in whom radial or femoral arterial access is difficult or not possible to achieve.

Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient.

RATIONALE: Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES: To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN: A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS: Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS: From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS: Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.

Flow-Sizing Critical Care Resources.

OBJECTIVES: To describe the factors affecting critical care capacity and how critical care organizations (CCOs) within academic centers in the U.S. flow-size critical care resources under normal operations, strain, and surge conditions. DATA SOURCES: PubMed, federal agency and American Hospital Association reports, and previous CCO survey results were reviewed. STUDY SELECTION: Studies and reports of critical care bed capacity and utilization within CCOs and in the United States were selected. DATA EXTRACTION: The Academic Leaders in the Critical Care Medicine Task Force established regular conference calls to reach a consensus on the approach of CCOs to "flow-sizing" critical care services. DATA SYNTHESIS: The approach of CCOs to "flow-sizing" critical care is outlined. The vertical (relation to institutional resources, e.g., space allocation, equipment, personnel redistribution) and horizontal (interdepartmental, e.g., emergency department, operating room, inpatient floors) integration of critical care delivery (ICUs, rapid response) for healthcare organizations and the methods by which CCOs flow-size critical care during normal operations, strain, and surge conditions are described. The advantages, barriers, and recommendations for the rapid and efficient scaling of critical care operations via a CCO structure are explained. Comprehensive guidance and resources for the development of "flow-sizing" capability by a CCO within a healthcare organization are provided. CONCLUSIONS: We identified and summarized the fundamental principles affecting critical care capacity. The taskforce highlighted the advantages of the CCO governance model to achieve rapid and cost-effective "flow-sizing" of critical care services and provide recommendations and resources to facilitate this capability. The relevance of a comprehensive approach to "flow-sizing" has become particularly relevant in the wake of the latest COVID-19 pandemic. In light of the growing risks of another extreme epidemic, planning for adequate capacity to confront the next critical care crisis is urgent.

Critical Care and Postoperative Management of the First Human Long Segment Orthotopic Tracheal Transplantation.

To outline the postoperative management of a long segment tracheal transplant in the ICU setting. DESIGN: The recipient required reconstruction of a long segment tracheal defect from a previous prolonged intubation. A male donor was chosen for a female recipient to enable analysis of the reepithelialization kinetics using fluorescence in situ hybridization to analyze the source of the new ciliated epithelium. SETTING: Transplant ICU at the Mount Sinai Hospital, New York, NY. PATIENTS: The female recipient was previously intubated for an asthma exacerbation and subsequently developed long segment tracheal stenosis and failed conventional management including dilatation, stenting, and six major surgical procedures rendering her chronically tracheostomy-dependent. The male donor suffered a massive subarachnoid hemorrhage and was subsequently pronounced brain dead. Organ procurement occurred after obtaining appropriate consent from the patient's family. INTERVENTIONS: The patient received a deceased donor tracheal allograft that included the thyroid gland, parathyroid glands, and the muscularis of the cervical and thoracic esophagus. Triple therapy immunosuppression (tacrolimus, mycophenolate mofetil, and a corticosteroid taper) was maintained. MEASUREMENTS AND MAIN RESULTS: The patient was initially managed postoperatively with deep sedation on ventilator via armored/reinforced endotracheal tube placed through a small tracheostomy located along the superior tracheal anastomosis. Serial bronchoscopies were performed for graft assessment, pulmonary toilet, and biopsies, which initially showed acute inflammatory changes but no features of acute allograft rejection. A euthyroid state was maintained but hypercalcemia developed. CONCLUSIONS: The ICU management of this first long segment orthotopic tracheal transplant required a multidisciplinary approach involving critical care, otolaryngology, transplant surgery, interventional pulmonary, endocrinology, 1:1 nursing throughout the recipient's transplant ICU stay, and respiratory therapy that resulted in the successful establishment of a viable tracheal airway and heralded the end of chronic tracheostomy dependence.

Postoperative Nursing Care of a Deceased Donor Tracheal Transplant Recipient.

INTRODUCTION: Certain airway disorders, such as tracheal stenosis, can severely affect the ability to breathe, reduce quality of life, and increase morbidity and mortality. Treatment options for long-segment tracheal stenosis include multistage tracheal replacement with biosynthetic material, autotransplantation, and allotransplantation. These interventions have not demonstrated long-term dependable results because of lack of adequate blood supply to the organ and ciliated epithelium. A new transplant program featuring single-stage long-segment tracheal transplant addresses this concern. CLINICAL FINDINGS: The patient was a 56-year-old woman with a history of obesity, type 2 diabetes, hypertension, hyperlipidemia, liver sarcoidosis, 105-pack-year smoking history, and asthma. A severe asthma exacerbation in 2014 required prolonged intubation, and she subsequently developed long-segment cricotracheal stenosis. In 2015 she underwent an unsuccessful tracheal resection followed by failed attempts at tracheal stenting and dilation procedures. These attempts at stenting resulted in a permanent extended-length tracheostomy and ultimately ventilator dependency. INTERVENTIONS: The patient underwent a single-stage long-segment deceased donor tracheal transplant. Important nursing considerations included hemodynamic monitoring, airway management and securement, graft assessment, stoma and wound care, nutrition, medication administration, and patient education. CONCLUSION: High-quality nursing care postoperatively in the intensive care unit is critical to safe and effective treatment of the tracheal transplant recipient and success of the graft. To effectively treat these patients, nurses need relevant education and training. This article is the first documentation of postoperative nursing care following single-stage long-segment tracheal transplant.

Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of Critical Care Medicine.

OBJECTIVES: The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions. DATA SOURCES AND STUDY SELECTION: Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product. DATA EXTRACTION AND SYNTHESIS: The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations. CONCLUSIONS: Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.

Outcomes and Prognosis Factors in Patients With Vena Cava Filters in a Quaternary Medical Center: A 5-Year Retrospective Analysis.

BACKGROUND: Indications for inferior vena cava filter (IVCF) placement are controversial. This study assesses the proportion of different indications for IVCF placement and the associated 30-day event rates and predictors for all-cause mortality, deep vein thrombosis (DVT), pulmonary embolism, and bleeding after IVCF placement. METHOD: In this 5-year retrospective cohort observational study in a quaternary care center, consecutive patients with IVCF placement were identified through cross-matching of 3 database sets and classified into 3 indication groups defined as "standard" in patients with venous thromboembolism (VTE) and contraindication to anticoagulants, "extended" in patients with VTE but no contraindication to anticoagulants, and "prophylactic" in patients without VTE. RESULTS: We identified 1248 IVCF placements, that is, 238 (19.1%) IVCF placements for standard indications, 583 (46.7%) IVCF placements for extended indications, and 427 (34.2%) IVCF placements for prophylactic indications. Deep vein thrombosis rates [95% confidence interval] were higher in the extended (8.06% [5.98-10.58]) and prophylactic (7.73% [5.38-10.68]) groups than in the standard group (3.36% [1.46-6.52]). Mortality rates were higher in the standard group (12.18% [8.31-17.03]) than in the extended group (7.55% [5.54-9.99]) and the prophylactic (5.85% [3.82-8.52]) group. Bleeding rates were higher in the standard group (4.62% [2.33-8.12]) than in the prophylactic group (2.11% [0.97-3.96]). Best predictors for VTE were acute medical conditions; best predictors for mortality were age, acute medical conditions, cancer, and Medicare health insurance. CONCLUSIONS: Prophylactic and extended indications account for the majority of IVCF placements. The standard indication is associated with the lowest VTE rate that may be explained by the competing risk of mortality higher in this group and related to the underlying medical conditions and bleeding risk. In the prophylactic group (no VTE at baseline), the exceedingly high DVT rate may be related to the IVCF placement.

Emergency physicians in critical care: where are we now?

OBJECTIVE: Prior to 2011, emergency physicians who completed critical care (CC) fellowship were unable to obtain board certification in the United States. Three pathways for CC board certification have since been established. This study explores the training, practice, and perceived challenges of emergency medicine/critical care fellows and emergency medicine/critical care physicians in the United States. METHODS: Anonymous institutional review board-approved survey distributed via email through an online survey engine from April to December 2016. Participants were recruited through national organizations and independent interest groups. Emergency physicians who were in CC fellowship or had completed a CC fellowship and were in practice in the United States participated voluntarily. RESULTS: Of the 162 respondents, 152 were included (92 physicians, 60 fellows). Eighty-nine percent ranged from 31-50 years old. Among fellows, 90% desired a dual discipline practice. Among physicians, 63% split their time between the emergency department and ICU. Seventy-one percent of physicians reported working in academic institutions. Among physicians engaged in a dual practice, mean full-time equivalent (±SD) devoted to the ED was 0.37 (±0.22), mean full-time equivalent for ICU was 0.47 (±0.22), and mean full-time equivalent for protected academic time was 0.28 (±0.19). Emergency medicine/critical care fellows and emergency medicine/critical care physicians identified numerous challenges associated with duality. CONCLUSIONS: Since the advent of critical care board certification for emergency physicians in the United States, there has been an increasing number of emergency physicians pursuing CC fellowships and achieving CC board certification. Emergency medicine/critical care physicians are venturing into a variety of practice models, demonstrating that the employment landscape remains plastic. Not unexpectedly, emergency medicine/critical care fellows and emergency medicine/critical care physicians are encountering challenges intrinsic to their duality.

Workforce, Workload, and Burnout in Critical Care Organizations: Survey Results and Research Agenda.

OBJECTIVES: This report provides analyses and perspective of a survey of critical care workforce, workload, and burnout among the intensivists and advanced practice providers of established U.S. and Canadian critical care organizations and provides a research agenda. DESIGN: A 97-item electronic survey questionnaire was distributed to the leaders of 27 qualifying organizations. SETTING: United States and Canada. PARTICIPANTS: Leaders of critical care organizations in the United States and Canada. INTERVENTIONS: None. DATA SYNTHESIS AND MAIN RESULTS: We received 23 responses (85%). The critical care organization survey recorded substantial variability of most organizational aspects that were not restricted by the critical care organization definition or regulatory mandates. The most common physician staffing model was a combination of full-time and part-time intensivists. Approximately 80% of critical care organizations had dedicated advanced practice providers that staffed some or all their ICUs. Full-time intensivists worked a median of 168 days (range 42-192 d) in the ICU (168 shifts = 24 7-d wk). The median shift duration was 12 hours (range, 7-14 hr), and the median number of consecutive shifts allowed was 7 hours (range 7-14 hr). More than half of critical care organizations reported having burnout prevention programs targeted to ICU physicians, advanced practice providers, and nurses. CONCLUSIONS: The variability of current approaches suggests that systematic comparative analyses could identify best organizational practices. The research agenda for the study of critical care organizations should include studies that provide insights regarding the effects of the integrative structure of critical care organizations on outcomes at the levels of our patients, our workforce, our work practices, and sustainability.

Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review.

OBJECTIVES: To assess-by literature review and expert consensus-workforce, workload, and burnout considerations among intensivists and advanced practice providers. DESIGN: Data were synthesized from monthly expert consensus and literature review. SETTING: Workforce and Workload section workgroup of the Academic Leaders in Critical Care Medicine Task Force. MEASUREMENTS AND MAIN RESULTS: Multidisciplinary care teams led by intensivists are an essential component of critical care delivery. Advanced practice providers (nurse practitioners and physician assistants) are progressively being integrated into ICU practice models. The ever-increasing number of patients with complex, life-threatening diseases, concentration of ICU beds in few centralized hospitals, expansion of specialty ICU services, and desire for 24/7 availability have contributed to growing intensivist staffing concerns. Such staffing challenges may negatively impact practitioner wellness, team perception of care quality, time available for teaching, and length of stay when the patient to intensivist ratio is greater than or equal to 15. Enhanced team communication and reduction of practice variation are important factors for improved patient outcomes. A diverse workforce adds value and enrichment to the overall work environment. Formal succession planning for ICU leaders is crucial to the success of critical care organizations. Implementation of a continuous 24/7 ICU coverage care model in high-acuity, high-volume centers should be based on patient-centered outcomes. High levels of burnout syndrome are common among intensivists. Prospective analyses of interventions to decrease burnout within the ICU setting are limited. However, organizational interventions are felt to be more effective than those directed at individuals. CONCLUSIONS: Critical care workforce and staffing models are myriad and based on several factors including local culture and resources, ICU organization, and strategies to reduce burden on the ICU provider workforce. Prospective studies to assess and avoid the burnout syndrome among intensivists and advanced practice providers are needed.

Critical Care Organizations: Business of Critical Care and Value/Performance Building.

OBJECTIVE: New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for value-based care. DESIGN: Relevant medical literature was accessed through a literature search. Material published by federal health agencies and other specialty organizations was also reviewed. Collaboratively and iteratively, taskforce members corresponded by electronic mail and held monthly conference calls to finalize this report. SETTING: The business and value/performance critical care organization building section comprised of leaders of critical care organizations with expertise in critical care administration, healthcare management, and clinical practice. MEASUREMENTS AND MAIN RESULTS: Two phases of critical care organizations care integration are described: "horizontal," within the system and regionalization of care as an initial phase, and "vertical," with a post-ICU and postacute care continuum as a succeeding phase. The tools required for the clinical and financial transformation are provided, including the essential prerequisites of forming a critical care organization; the manner in which a critical care organization can help manage transformational domains is considered. Lastly, how to achieve organizational health system support for critical care organization implementation is discussed. CONCLUSIONS: A critical care organization that incorporates functional clinical horizontal and vertical integration for ICU patients and survivors, aligns strategy and operations with those of the parent health system, and encompasses knowledge on finance and risk will be better positioned to succeed in the value-based world.

Critical Care Organizations: Building and Integrating Academic Programs.

OBJECTIVE: Academic medical centers in North America are expanding their missions from the traditional triad of patient care, research, and education to include the broader issue of healthcare delivery improvement. In recent years, integrated Critical Care Organizations have developed within academic centers to better meet the challenges of this broadening mission. The goal of this article was to provide interested administrators and intensivists with the proper resources, lines of communication, and organizational approach to accomplish integration and Critical Care Organization formation effectively. DESIGN: The Academic Critical Care Organization Building section workgroup of the taskforce established regular monthly conference calls to reach consensus on the development of a toolkit utilizing methods proven to advance the development of their own academic Critical Care Organizations. Relevant medical literature was reviewed by literature search. Materials from federal agencies and other national organizations were accessed through the Internet. SETTING: The Society of Critical Care Medicine convened a taskforce entitled "Academic Leaders in Critical Care Medicine" on February 22, 2016 at the 45th Critical Care Congress using the expertise of successful leaders of advanced governance Critical Care Organizations in North America to develop a toolkit for advancing Critical Care Organizations. MEASUREMENTS AND MAIN RESULTS: Key elements of an academic Critical Care Organization are outlined. The vital missions of multidisciplinary patient care, safety, and quality are linked to the research, education, and professional development missions that enhance the value of such organizations. Core features, benefits, barriers, and recommendations for integration of academic programs within Critical Care Organizations are described. Selected readings and resources to successfully implement the recommendations are provided. Communication with medical school and hospital leadership is discussed. CONCLUSIONS: We present the rationale for critical care programs to transition to integrated Critical Care Organizations within academic medical centers and provide recommendations and resources to facilitate this transition and foster Critical Care Organization effectiveness and future success.

Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

AIM: To study the early postoperative intensive care unit (ICU) management and complications in the first 2 wk of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Our study is a retrospective, observational study performed at Icahn School of Medicine at Mount Sinai, quaternary care hospital in New York City. All adult patients who underwent CRS and HIPEC between January 1, 2007 and December 31, 2012 and admitted to ICU postoperatively were studied. Fifty-one patients came to the ICU postoperatively out of 170 who underwent CRS and HIPEC therapy during the study period. Data analysis was performed using descriptive statistics. RESULTS: Of the 170 patients who underwent CRS and HIPEC therapy, 51 (30%) came to the ICU postoperatively. Mean ICU length of stay was 4 d (range 1-60 d) and mean APACHE II score was 15 (range 7-23). Thirty-one/fifty-one (62%) patients developed postoperative complications. Aggressive intraoperative and postoperative fluid resuscitation is required in most patients. Hypovolemia was seen in all patients and median amount of fluids required in the first 48 h was 6 L (range 1-14 L). Thirteen patients (25%) developed postoperative hypotension with seven requiring vasopressor support. The major cause of sepsis was intraabdominal, with 8 (15%) developing anastomotic leaks and 5 (10%) developing intraabdominal abscess. The median survival was 14 mo with 30 d mortality of 4% (2/51) and 90 d mortality of 16% (8/51). One year survival was 56.4% (28/51). Preoperative medical co morbidities, extent of surgical debulking, intraoperative blood losses, amount of intra op blood products required and total operative time are the factors to be considered while deciding ICU vs non ICU admission. CONCLUSION: Overall, ICU outcomes of this study population are excellent. Triage of these patients should consider preoperative and intraoperative factors. Intensivists should be vigilant to aggressive postop fluid resuscitation, pain control and early detection and management of surgical complications.

Enteral nutrition administration in a surgical intensive care unit: Achieving goals with better strategies.

AIM: To evaluate the impact of an enteral feeding protocol on administration of nutrition to surgical intensive care unit (SICU) patients. METHODS: A retrospective chart review was conducted on patients initiated on enteral nutrition (EN) support during their stay in a 14 bed SICU. Data collected over a seven-day period included date of tube feed initiation, rate initiated, subsequent hourly rates, volume provided daily, and the nature and length of interruptions. The six months prior to implementation of the feeding protocol (pre-intervention) and six months after implementation (post-intervention) were compared. One hundred and four patients met criteria for inclusion; 53 were pre-intervention and 51 post-intervention. RESULTS: Of the 624 patients who received nutrition support during the review period, 104 met the criteria for inclusion in the study. Of the 104 patients who met criteria outlined for inclusion, 64 reached the calculated goal rate (pre = 28 and post = 36). The median time to achieve the goal rate was significantly shorter in the post-intervention phase (3 d vs 6 d; P = 0.01). The time to achieve the total recommended daily volume showed a non-significant decline in the post-intervention phase (P = 0.24) and the overall volume administered daily was higher in the post-intervention phase (61.6% vs 53.5%; P = 0.07). While the overall interruptions data did not reach statistical significance, undocumented interruptions (interruptions for unknown reasons) were lower in the post-intervention phase (pre = 23/124, post = 9/96; P = 0.06). CONCLUSION: A protocol delineating the initiation and advancement of EN support coupled with ongoing education can improve administration of nutrition to SICU patients.

Getting to zero: Reduction in the incidence of multidrug-resistant organism infections using an integrated infection control protocol in an intensive care unit.

Environmental cleaning is a vital component of infection control. We describe the use of an integrated infection control protocol in an intensive care unit and its influence on multidrug-resistant organism infection rates. Sustained reductions in multidrug-resistant organism infections can be achieved if individual processes and weaknesses in intensive care unit environments are identified and addressed in a systematic and comprehensive manner.