Intensive care for critically ill elderly: mortality, costs, and quality of life. Review of the literature.

The literature on outcomes of intensive care for the elderly with regard to intensive care unit utilization, mortality, hospital costs and charges, and quality of life after intensive care were reviewed. Publications in the English literature, which evaluated intensive care and included elderly populations, were obtained from review of Index Medicus and MEDLINE. We conclude that age alone is not an acceptable predictor of critical illness with regard to mortality and quality of life of survivors. A therapeutic trial and appropriately discontinuing life support may lead to better utilization of intensive care. Additional data are needed on long-term mortality and quality of life after hospital discharge.

Altered pulmonary capillary permeability complicating recovery from diabetic ketoacidosis.

Self-limited noncardiogenic interstitial pulmonary edema probably reflecting altered permeability of the pulmonary capillary membrane is reported in a patient being treated for severe diabetic ketoacidosis. The possible etiology, associated findings, and therapy with continuous positive airway pressure (CPAP) by facemask are discussed.

Retroperitoneal air dissection associated with mechanical ventilation.

The radiologic patterns, etiology, and possible consequences of gas dissection into the retroperitoneal space from pulmonary sources are reviewed in three patients requiring mechanical ventilation. Airway disruption appears to be related to peak airway pressures, underlying pulmonary disease, and the patient's hemodynamic condition and may cause different forms of interstitial emphysema and air embolization, which may lead to severe respiratory or circulatory dysfunction. Gas migration to the retroperitoneum and, secondarily, into the peritoneal cavity should be considered in the differential diagnosis of free intra-abdominal gas.

Subjective and objective measurement of tidal volume in critically ill patients.

Subjective assessment of the respiratory rate and the adequacy of tidal ventilation are the oldest and most widely practiced forms of respiratory monitoring in critically ill patients. Surprisingly, this method of assessment has itself never been evaluated in patients. The estimation of tidal volume in nine patients was performed by full-time intensive care unit (ICU) personnel and compared to the objective measurement of using a calibrated and validated respiratory inductive plethysmograph (RIP). Linear correlation analysis was performed. Poor correlation between clinical estimation by ICU personnel and actual measurement by RIP was revealed in all cases. A widespread and potentially dangerous tendency to overestimate tidal volume was noted. These data suggest that subjective assessment of tidal volume is inaccurate in critically ill patients and that the development of techniques of continuous, nonobtrusive and objective monitoring are to be encouraged.

High-frequency jet ventilation during the treatment of acute fulminant pulmonary edema.

High-frequency jet ventilation (HFJV) was used during the treatment of fulminant pulmonary edema in a 45-year-old man so that toxic levels of oxygen could be avoided when conventional methods of ventilation in combination with high levels of PEEP (20 cm H2O) were unsuccessful in raising PaO2. On each of four occasions, HFJV resulted in improved arterial oxygenation when compared with conventional modes.

Continuous positive airway pressure without tracheal intubation in spontaneously breathing patients.

Indications for the use of therapy with continuous positive airway pressure (CPAP) in spontaneously breathing patients are increasing in number. The value of this technique without tracheal intubation was investigated in 14 patients with acute respiratory distress. In most patients (eight patients, or 57 percent) the technique was successful, as evidenced by avoidance of the necessity for tracheal intubation and improvements in clinical appearance, arterial oxygen pressure, and chest x-ray films. Complications were observed in three patients, but these necessitated discontinuation of therapy in only one. The use of this technique allows avoidance of endotracheal intubation and mechanical ventilation, with their attendant risks.

Cardiorespiratory effects of flexible fiberoptic bronchoscopy in critically ill patients.

The flexible fiberoptic bronchoscope is used increasingly often as a multipurpose instrument in critical care medicine. In poor risk patients who need continuous mechanical ventilation, rigid open tube bronchoscopy is a problem. With the flexible fiberoptic bronchoscope, however, diagnostic and therapeutic procedures can be carried out without interruption of ongoing mechanical ventilation. This procedure offers the possibility of bronchoscopy with reduced risk in debilitated patients. However, in these critically ill patients, the cardiopulmonary system is functioning at the borderline of its ability. Therefore, even the small changes in ventilation pattern caused by flexible fiberoptic bronchoscopy (FFB) may in some cases cause dangerous cardiopulmonary distress. For example, changes of intrabronchial pressure, tidal volume, PaO2, PaCO2 and cardiac output may be caused by the procedure. Further, it is of great importance to restrict suction through the instrument to short periods to avoid dangerous alterations in the ventilation perfusion relationship. Since serious complications may occur, it is mandatory that the bronchoscopist be aware of the potential pathophysiologic effects of FFB during mechanical ventilation of critically ill patients.

Enteral and intranasal treatment for vasopressor-dependent hypotension in C1 tetraplegia.

A complete traumatic C1 spinal cord lesion leads to bradycardia and temporary hypotension until fluid administration can restore blood volume and pressure to the autosympathectomized capacitance vessels. In spite of adequate volume status, however, our patient required intravenous pressor agents to maintain adequate arterial and central venous pressure several weeks after injury. Using oral pseudoephedrine and occasional nasal phenylephrine, intravenous lines could be removed with maintenance of arterial pressure and resolution of bradycardia.

Intra-aortic administration of epinephrine above aortic occlusion does not alter outcome of experimental cardiopulmonary resuscitation.

Intra-aortic balloon occlusion during experimental cardiopulmonary resuscitation (CPR) improves coronary perfusion pressure and resuscitability and provides unique access to the central circulation. It has been hypothesized that administration of epinephrine into the aortic arch in combination with aortic occlusion would further improve haemodynamics during CPR, resuscitability and 24 h survival. In 16 anaesthetised dogs intravascular catheters were placed for hemodynamic and blood gas monitoring. An aortic balloon catheter was placed by femoral artery insertion with its tip just distal to the left subclavian artery. Ventricular fibrillation for 7.5 min without CPR, 2.5 min of Basic Life Support with chest compressions and ventilation with 100% oxygen were followed by 30 min of Advanced Cardiac Life Support (ACLS) with systemic canine drug dosages. The intra-aortic balloon was inflated when ACLS started and gradually deflated shortly after restoration of spontaneous circulation (ROSC). Epinephrine, in 100 microg/kg boluses every 5 min until the heart was restarted or 30 min had elapsed was administered through the intra-aortic catheter in the experimental group (n = 8) and via a central venous catheter in the control group (n = 8). Coronary perfusion pressure increased during the ACLS period in both groups (P < 0.05) with no difference between the groups and there was no difference in the frequency of ROSC (experimental group 5/8, control group 4/8). Furthermore with respect to 24 h survival, there was no difference between the experimental group (2/8) and the control group (3/8). Severe macroscopic haemorrhagic necrosis of the myocardium in the dogs with ROSC was found in 4/5 in the experimental group compared to 1/4 in the control group. In conclusion, intra-aortic administration of 100 microg/kg epinephrine doses combined with aortic occlusion during experimental CPR did not alter outcome.

Future directions for resuscitation research. I. Advanced airway control measures.

The efficacy of 'basic' airway control without equipment, using the combination of backward tilt of the head, forward displacement of the mandible, and separation of lips and teeth (i.e. the triple airway maneuver) has been well established. Direct mouth-to-mouth and mouth-to-nose ventilation must continue to be taught to the public. Further improvements are needed for pocket-size mouth-to-mouth barriers to combat infection risks. Dissemination of appropriate information on disease transmission is needed to ensure ventilation by health professionals, using exhaled air ventilation adjuncts and other devices. Much knowledge exists about the pathophysiology of airway obstruction. For patients in coma or anesthesia with airway obstruction, which resists basic airway control measures and standard tracheal intubation, available 'advanced' airway control measures should be mastered and improved. Preparedness for advanced airway control measures differs between elective management of the anticipated difficult airway for anesthesia and emergency airway control with unanticipated difficulties encountered during the ordinary sequential application of measures. Challenges include education research and development of new devices. For airway clearing, pharyngeal intubation, difficult tracheal intubation, cricothyrotomy, transtracheal jet ventilation and emergency use of oxygen - what could and should be taught, to whom, and how? Which new devices and training systems should be developed? The most important alternative to orotracheal or nasotracheal intubation recommended for the development of novel devices and teaching methods for health professionals, are cricothyrotomy (with wide enough airway to also enable spontaneous breathing of air), and translaryngeal or transtracheal oxygen jet ventilation. We recommend openness in communication and joint planning between anesthesiologists, emergency care providers, and appropriate educators, engineers and industries.

Future directions for resuscitation research. V. Ultra-advanced life support.

Standard external cardiopulmonary resuscitation (SECPR) frequently produces very low perfusion pressures, which are inadequate to achieve restoration of spontaneous circulation (ROSC) and intact survival, particularly when the heart is diseased. Ultra-advanced life support (UALS) techniques may allow support of vital organ systems until either the heart recovers or cardiac repair or replacement is performed. Closed-chest emergency cardiopulmonary bypass (CPB) provides control of blood flow, pressure, composition and temperature, but has so far been applied relatively late. This additional low-flow time may preclude conscious survival. An easy, quick method for vessel access and a small preprimed system that could be taken into the field are needed. Open-chest CPR (OCCPR) is physiologically superior to SECPR, but has also been initiated too late in prior studies. Its application in the field has recently proven feasible. Variations of OCCPR, which deserve clinical trials inside and outside hospitals, include 'minimally invasive direct cardiac massage' (MIDCM), using a pocket-size plunger-like device inserted via a small incision and 'direct mechanical ventricular actuation' (DMVA), using a machine that pneumatically drives a cup placed around the heart. Other novel UALS approaches for further research include the use of an aortic balloon catheter to improve coronary and cerebral blood flow during SECPR, aortic flush techniques and a double-balloon aortic catheter that could allow separate perfusion (and cooling) of the heart, brain and viscera for optimal resuscitation of each. Decision-making, initiation of UALS methods and diagnostic evaluations must be rapid to maximize the potential for ROSC and facilitate decision-making regarding long-term circulatory support versus withdrawal of life support for hopeless cases. Research and development of UALS techniques needs to be coordinated with cerebral resuscitation research.

History of organ donation by patients with cardiac death.

When successful solid organ transplantation was initiated almost 40 years ago, its current success rate was not anticipated. But continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, but also from using organs from different sources. Each potential solution has raised ethical concerns and has variably resulted in societal acclaim, censure, and apathy. Transplant surgery is now well accepted, and the list of transplant candidates has grown far quicker than the availability of organs. More than 30,000 patients were awaiting organs for transplantation at the end of March 1993. While most organs came from donors declared dead by brain criteria, the increasing shortage of donated organs has prompted a reexamination of prior restrictions of donor groups. Recently, organ procurement from donors with cardiac death has been reintroduced in the United States. This practice has been mostly abandoned by the U.S. and some, though not all, other countries. Transplantation has been more successful using organs procured from heart-beating, "brain dead" cadavers than organs from non-heart-beating cadavers. However, recent advances have led to success rates with organs from non-heart-beating donors that may portend large increases in organ donation and procurement from this source.

Future of critical care.

Critical care, as a specialty in both nursing and medicine, is well recognized and the number of people requiring hospitalization for critical illnesses continues to increase. The purpose of this paper is to examine the future and the changes that lie ahead in critical care. New and expanding roles for nurses are projected along with a continued refinement and expansion of the critical care medicine subspecialty for physicians. A variety of changes in critical care are anticipated that reflect our increasing abilities in biotechnology, basic and clinical research, and data management. These changes are viewed for their obvious impact on cost, ethical controversies, and patient care and outcome.

Simulation-based training at the University of Pittsburgh.

The following article reviews the experience of using human simulators for medical education at the University of Pittsburgh in the Department of Anesthesiology and Critical Care Medicine. The intent of the authors is to provide the reader with an overview of 1) what human simulators can do, 2) the components of a simulation training facility, 3) some of the economic considerations in operating a simulation training facility, and 4) how this centre is made use of.