In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of ...the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.
To review and revise the 1987 pediatric brain death guidelines.
Relevant literature was reviewed. Recommendations were developed using the Grading of Recommendations Assessment, Development and ...Evaluation (GRADE) system.
1) Determination of brain death in term newborns, infants, and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma. Because of insufficient data in the literature, recommendations for preterm infants <37 wks gestational age are not included in this guideline. 2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. 3) Two examinations, including apnea testing with each examination separated by an observation period, are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hrs for term newborns (37 wks gestational age) to 30 days of age and 12 hrs for infants and children (>30 days to 18 yrs) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for ≥24 hrs if there are concerns or inconsistencies in the examination. 4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial Paco2 20 mm Hg above the baseline and ≥60 mm Hg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. 5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be used to assist the clinician in making the diagnosis of brain death a) when components of the examination or apnea testing cannot be completed safely as a result of the underlying medical condition of the patient; b) if there is uncertainty about the results of the neurologic examination; c) if a medication effect may be present; or d) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should be performed and components that can be completed must remain consistent with brain death. In this instance, the observation interval may be shortened and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. 6) Death is declared when these criteria are fulfilled.
The objective of this study was to determine the prevalence of ICU delirium in children less than 18 years old that underwent cardiac surgery within the last 30 days. The secondary aim of the study ...was to identify risk factors associated with ICU delirium in postoperative pediatric cardiac surgical patients.
A 1-day, multicenter point-prevalence study of delirium in pediatric postoperative cardiac surgery patients.
Twenty-seven pediatric cardiac and general critical care units caring for postoperative pediatric cardiac surgery patients in North America.
All children less than 18 years old hospitalized in the cardiac critical care units at 06:00 on a randomly selected, study day.
Eligible children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the study team in collaboration with the bedside nurse.
Overall, 181 patients were enrolled and 40% (n = 73) screened positive for delirium. There were no statistically significant differences in patient demographic information, severity of defect or surgical procedure, past medical history, or postoperative day between patients screening positive or negative for delirium. Our bivariate analysis found those patients screening positive had a longer duration of mechanical ventilation (12.8 vs 5.1 d; p = 0.02); required more vasoactive support (55% vs 26%; p = 0.0009); and had a higher number of invasive catheters (4 vs 3 catheters; p = 0.001). Delirium-positive patients received more total opioid exposure (1.80 vs 0.36 mg/kg/d of morphine equivalents; p < 0.001), did not have an ambulation or physical therapy schedule (p = 0.02), had not been out of bed in the previous 24 hours (p < 0.0002), and parents were not at the bedside at time of data collection (p = 0.008). In the mixed-effects logistic regression analysis of modifiable risk factors, the following variables were associated with a positive delirium screen: 1) pain score, per point increase (odds ratio, 1.3; 1.06-1.60); 2) total opioid exposure, per mg/kg/d increase (odds ratio, 1.35; 1.06-1.73); 3) SBS less than 0 (odds ratio, 4.01; 1.21-13.27); 4) pain medication or sedative administered in the previous 4 hours (odds ratio, 3.49; 1.32-9.28); 5) no progressive physical therapy or ambulation schedule in their medical record (odds ratio, 4.40; 1.41-13.68); and 6) parents not at bedside at time of data collection (odds ratio, 2.31; 1.01-5.31).
We found delirium to be a common problem after cardiac surgery with several important modifiable risk factors.
Background
Chronic rhinosinusitis (CRS) causes a great deal of morbidity. There are a multitude of causal factors, though their precise contribution to symptom severity has yet to be defined. We ...hypothesized that exposure to both primary and secondhand tobacco smoke would correlate with more severe symptoms of CRS.
Methods
This is a prospective cross‐sectional study performed at an academic tertiary care medical center from 2010 to 2013. A total of 85 consecutive patients with chronic sinusitis were screened; 70 with medically refractory CRS requiring functional Endoscopic sinus surgery (FESS) were enrolled. Recent tobacco exposure was assessed using serum cotinine levels. Sinonasal mucosa was biopsied to assess ciliary architecture. Demographics, medical history, tobacco and environmental exposures, and computed tomography (CT) imaging were also collected. Two quality of life (QOL) surveys were administered: one disease specific, Sinonasal Outcomes Test‐20 (SNOT‐20), and one general, Short Form‐12 (SF‐12). Results were correlated with the aforementioned exposures.
Results
The 70 patients had an average age of 46 years, and 42% were male. Variables that correlated with worse SNOT‐20 scores included serum cotinine (r = 0.43, p = 0.002), number of cigarettes smoked daily (r = 0.27, p = 0.03), and number of secondhand cigarettes exposed to per day (r = 0.29, p = 0.04). There were no significant correlations between SNOT‐20 scores and Lund–MacKay or axonemal ultrastructural abnormalities (AUA)‐ciliary scores. The two five‐variable models best predicted disease‐specific QOL.
Conclusions
Increased amounts of serum cotinine and primary and secondhand smoke exposure were associated with worse sinonasal QOL. This study establishes an objective relationship between smoke exposure and patient‐perceived severity of CRS, emphasizing the importance of tobacco cessation counseling as part of management.
1. Utilizing resident needs-based assessments, the participants will self-report the ability to survey residents in order to identify and fill resident-reported training deficiencies.
2. Utilizing a ...multimodal approach, the participants will self-report the ability to design, integrate, implement, and tailor a surgical palliative care curriculum.
Formal integration of palliative care education is a recognized deficiency of general surgery education. A needs assessment of general surgery residents identified a desire to implement a resident-driven surgical palliative care curriculum. A novel, resident-driven surgical palliative care curriculum was created and implemented with close interprofessional collaboration.
Palliative care is essential for optimal surgical care. Currently, there is a lack of palliative care education within general surgery training.
A palliative care needs/knowledge assessment was performed with general surgery residents of a tertiary care center academic program. The survey identified clinical subject matter of emphasis. A curriculum was then created, validated, and implemented, in collaboration with the palliative care department, to target these resident-driven initiatives. A post-curriculum survey will be conducted to assess resident comfort and effectiveness in providing palliative care, including usage of a surgical palliative care note template.
The assessment was answered by 38/77 (49.4%) residents. Majority of respondents (60.5%) lacked formal palliative care education/training. Most respondents (74.3%) have participated in palliative care conferences with 42.1% of respondents being the primary surgical liaison. There was no correlation between PGY level and palliative care conference participation. Eighty-seven percent of respondents were interested in a palliative care curriculum. Seventy-six percent of respondents were unaware of the surgical palliative care note template and only 3.9% of respondents used the template within the past 6 months. Residents identified several palliative care topics for curriculum emphasis including DNR/DNI discussions (77%), goals of care/conducting family conference (69%), delivering serious news (63%), palliative surgery (63%), and palliative care and hospice referrals (60%).
Despite their need to practice surgical palliative care, the majority of general surgery residents were not comfortable with essential surgical palliative care subjects and skills and desired formal training. To address this educational gap, a novel surgical palliative care curriculum was developed and is currently being implemented with interprofessional collaboration between the surgical and palliative care departments. A post-curriculum survey will be conducted to assess resident understanding and application of the curriculum.
Surgical Palliative Care/Interdisciplinary Teamwork / Professionalism
The start of transpyloric feedings is often delayed because of challenges in reliably placing tubes blindly at the bedside.
To determine whether tube placement with the guidance of a noninvasive ...computerized electromagnetic device shortens the time needed to achieve accurate placement of transpyloric feeding tubes in critically ill children.
In a prospective, randomized trial in a tertiary-care, university-affiliated pediatric intensive care unit, 49 children requiring transpyloric feeding tube placement were randomized to have their tube placed by using conventional blind technique or with the assistance of a noninvasive electromagnetic device.
Twenty-seven patients were randomized to blind placement, and 22 were randomized to the electromagnetic device group. The time required to place the tubes successfully was significantly longer (P < .03) in the electromagnetic device group (median, 9.5 minutes; 95% confidence interval, 7-13 minutes) compared with the conventional placement group (median, 5 minutes; 95% confidence interval, 4.0-7.0 minutes).
Placement of transpyloric feeding tubes with the guidance of a noninvasive electromagnetic device significantly increases the time required for accurate placement. Because placement of transpyloric feeding tubes in critically ill children is common practice in many pediatric intensive care units, technology that delays satisfactory placement may be counterproductive in experienced hands.
Abstract
Pediatric overweight and obesity rates have reached epidemic proportions and continue to rise globally. Many long-term complications have been described about the impact of obesity; however, ...little work has been done in the area of acute and critical illness in children. Available evidence suggests that childhood obesity can impact acute and critical illness when compared with normal weight cohorts. This review will discuss the available literature on the impact of pediatric obesity during acute and critical illness.
PDF
