Category Archives: Critical Care

Palliative Care in Trauma Patients

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“Older trauma patients present with poor preinjury functional status and more comorbidities. Advances in care have increased the chance of survival from previously fatal injuries with many left debilitated with chronic critical illness and severe disability. Palliative care (PC) is ideally suited to address the goals of care and symptom management in this critically ill population. A retrospective chart review was done to identify the impact of PC consults on hospital length of stay (LOS), ICU LOS, and surgical decisions.”

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Management of Iatrogenic Cervical Esophageal Perforations

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“Esophageal perforations are difficult to diagnose and have a high mortality rate. The existing studies on esophageal perforations address treatment by anatomic location and by cause, but few focus specifically on iCEPs. The management of iCEPs is controversial. There is a need for additional prospective studies comparing treatment options for iCEPs to establish a gold standard treatment and to assess for the expanding role of endoscopic interventions.” (Chen)

(Chen)
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Article of interest: A Clinician’s Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients

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De Laet IE, et al. A Clinician’s Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients. Crit Care. 2020 Mar 24;24(1):97.

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The Confusion Assessment Method (CAM) for the ICU-7 Delirium Severity Scale

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Khan BA, et al. The Confusion Assessment Method for the ICU-7 Delirium Severity
Scale: A Novel Delirium Severity Instrument for Use in the ICU. Crit Care Med. 2017 May;45(5):851-857.

Measurements and Main Results: Patients received the CAM-ICU, Richmond Agitation-Sedation Scale (RASS), and Delirium Rating Scale-Revised (DRS-R)-98 assessments. A 7-point scale (0-7) was derived from responses to the CAM-ICU and RASS items. CAM-ICU-7 showed high internal consistency (Cronbach’s alpha=0.85) and good correlation with DRS-R-98 scores (correlation coefficient=0.64). Known-groups validity was supported by the separation of mechanically ventilated and non-ventilated assessments. Median CAM-ICU-7 scores demonstrated good predictive validity with higher odds (OR=1.47; 95% CI=1.30-1.66) of inhospital mortality, and lower odds (OR=0.8; 95% CI=0.72-0.9) of being discharged home after adjusting for age, race, gender, severity of illness, and chronic comorbidities. Higher CAM-ICU-7 scores were also associated with increased length of ICU stay (p=0.001).

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The PAUSE study: Safety of perioperative DOAC management in patients with atrial fibrillation

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A discussion during a previous conference included the perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant (DOAC).

Reference: Douketis JD, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Internal Medicine. 2019 Aug 5; doi:10/1001/jamainternmed.2019.2431

Summary: Each year, 1 in 6 patients with AF, or an estimated 6 million patients worldwide, will require perioperative anticoagulant management. When DOAC regimens became available for clinical use in AF, starting in 2010, no studies had been conducted to inform the timing of perioperative DOAC therapy interruption and resumption, whether heparin bridging should be given, and whether preoperative coagulation function testing was needed. Uncertainty about the perioperative management of DOACs may be associated with unsubstantiated practices and increased harm to patients.

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Open vs endovascular revascularization for acute limb ischemia: a review of major trials

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One discussion this week involved open surgical versus endovascular revascularization for acute limb ischemia (ALI).

Reference: Wang JC, Kim AH, Kashyap VS. Open surgical or endovascular revascularization for acute limb ischemia. Journal of Vascular Surgery. 2016 Jan;63(1):270-278. doi:10/1016/j.jvs.2015.09.055.

Summary: Peripheral arterial disease affects approximately 10 million Americans. It can lead to lower extremity ischemic rest pain or tissue loss (Rutherford classification 4 to 6, or Fontaine classification III and IV). Acute limb ischemia (ALI) is defined as the presence of symptoms within 2 weeks of onset. ALI pathogenesis includes vascular stenoses with subsequent in situ thrombosis or thromboembolism from a cardiac or aortoiliac source. Stenotic lesions may indicate untreated comorbidities (eg, hypertension, hypercholesterolemia, diabetes, or tobacco use), whereas thromboembolisms implicate undiagnosed cardiac arrhythmias, myocardial infarction (MI), or mural thrombus. Limb loss risk due to ALI can be as high as 40% with an attendant mortality rate of 15% to 20% (p.270).

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The benefit of urinary alkalinization and mannitol in the treatment of rhabdomyolysis

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One discussion this week included the benefits of urinary alkalinization and mannitol in treating rhabdomyolysis (RM).

Reference: Bada A, Smith N, and Surgical Critical Care Guidelines Committee. Rhabdomyolysis: Prevention and Treatment. SurgicalCritical Care.net. 2018, Jul 24.

Summary: RM is the dissolution muscle and release of potentially toxic intracellular components into the systemic circulation. RM has the potential to cause myoglobinuric ARF in 10-15% of such patients. Overall, 10-15% of ARF in the United States is from RM.

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