Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction?

PURPOSE OF REVIEW: Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined. RECENT FINDINGS: Anesthesiologists have taken key roles in improving patient safety in the operating room. Anesthesia-related mortality rates have decreased from 20 deaths per 100 000 anesthetics in the early 1980s to less than one death per 100 000 currently. Anesthesiologist-intensivists remain rare (less than 5% of certified anesthesiologists), but increasingly play multiple roles within multidisciplinary teams. This review outlines the roles of intensivists in performance improvement, perioperative assessment; sedation services, extracorporeal and mechanical support, and code/rapid response teams. Critical-care physicians, by definition, work in collaborative multispecialty and multidisciplinary teams that make it difficult to isolate each team member's precise contribution to healthcare value. SUMMARY: Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes.

Variability of fluid administration during exploratory laparotomy for abdominal trauma.

BACKGROUND: Approximately 8% of traumatically injured patients require transfusion with packed red blood cells (pRBC) and only 1% to 2% require massive transfusion. Intraoperative massive transfusion was defined as requiring greater than 5 units (u) of pRBC in 4 hours. Despite the majority of patients not requiring transfusion, the appropriate amount and type of crystalloid administered during the era of damage control resuscitation have not been analyzed. We sought to determine the types of crystalloid used during trauma laparotomies and the potential effects on resuscitation. METHODS: Patients who underwent laparotomy after abdominal trauma from January 2014 to December 2016 at the University of Cincinnati Medical Center were identified. Patients were grouped based on requiring 0u, 1u to 4u, and ≥5u pRBC during intraoperative resuscitation. Demographic, physiologic, pharmacologic, operative, and postoperative data were collected. Statistical analysis was performed with Kruskal-Wallis test and Pearson's correlation coefficient. RESULTS: Lactated Ringer's (LR) solution was the most used crystalloid type received in the 0u and 1u to 4u pRBC cohorts, whereas normal saline (NS) was the most common in the ≥5u pRBC cohort. Most patients received two types of crystalloid intraoperatively. NS and LR were most frequently the first crystalloids administered, with Normosol infusion occurring later. The amount of crystalloid received correlated with operative length, but did not correlate with the estimated blood loss. Neither the type of crystalloid administered nor the anesthesia provider type was associated with changes in postoperative resuscitation parameters or electrolyte concentrations. DISCUSSION: There is a wide variation in the amount and types of crystalloids administered during exploratory laparotomy for trauma. Interestingly, the amount or type of crystalloid given did not affect resuscitation parameters regardless of blood product requirement. LEVEL OF EVIDENCE: Level IV.

Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies at a University Medical Center.

BACKGROUND: Intraoperative lung-protective ventilation (ILPV) is defined as tidal volumes <8 mL/kg ideal bodyweight and is increasingly a standard of care for major abdominal surgical procedures performed under general anesthesia. In this study, we report the result of a quality improvement initiative targeted at improving adherence to ILPV guidelines in a large academic teaching hospital. METHODS: We performed a time-series study to determine whether anesthesia provider adherence to ILPV was affected by certain improvement interventions and patient ideal body weight (IBW). Tidal volume data were collected at 3 different time points for 191 abdominal surgical cases from June 2014 through April 2015. Improvement interventions during that period included education at departmental grand rounds, creation of a departmental ILPV policy, feedback of tidal volume and failure rate data at grand rounds sessions, and reducing default ventilator settings for tidal volume. Mean tidal volume per kilogram of ideal body weight (VT/kg IBW) and rates of noncompliance with ILPV were analyzed before and after the interventions. A survey was administered to assess provider attitudes after implementation of improvement interventions. Responses before and after interventions and between physician and nonphysician providers were analyzed. RESULTS: Reductions in mean VT/kg IBW and rates of failure for providers to use ILPV occurred after improvement interventions. Patients with IBW <65 kg received higher VT/kg IBW and had higher rates of failure to use ILPV than patients with IBW >65 kg. Surveyed providers demonstrated stronger agreement to having knowledge and practice consistent with ILPV after interventions. CONCLUSIONS: Our interventions improved anesthesia provider adherence to low tidal volume ILPV. IBW was found to be an important factor related to provider adherence to ILPV. Provider attitudes about their knowledge and practice consistent with ILPV also changed with our interventions.

Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia?

For the past 4 decades, the prone position has been employed as an occasional rescue option for patients with severe hypoxemia unresponsive to conventional measures applied in the supine orientation. Proning offers a high likelihood of significantly improved arterial oxygenation to well selected patients, but until the results of a convincing randomized trial were published, its potential to reduce mortality risk remained in serious doubt. Proning does not benefit patients of all disease severities and stages but may be life-saving for others. Because it requires advanced nursing skills and escalation of monitoring surveillance to deploy safely, its place as an early stage standard of care depends on the definition of that label.