Upper airway obstruction in children is a serious and potentially life-threatening problem. There are numerous possible etiologies; the clinician should arrive at the correct diagnosis to avoid complications. The history of onset and the physical findings of strider and work of breathing will direct the focus of diagnostic studies. Endoscopy remains the best way to see the lesion, make the diagnosis, and plan therapy, However, radiology provides important clues and can be used to differentiate croup vs. supraglottitis, This article reviews, from a surgeon's standpoint, current strategies for evaluation and management of pediatric upper airway obstruction commonly seen in the intensive care setting.
Resuscitation refers to a series of therapeutic maneuvers intended to restore a hemorrhaging patient's cardiovascular system as well as to obtain surgical control of the source of bleeding and subsequently ensure adequate tissue perfusion postoperatively. The term "initial resuscitation" refers to interventions performed either in the field, in the ambulance en route to the hospital, or as part of the primary survey in the emergency center. Initial resuscitation of trauma patients should achieve the following objectives: a) identify potentially life-threatening injuries; b) optimize physiologic compensatory mechanisms; c) produce minimal immediate or long-term new injuries or complications; and d) assure maintenance of critical organ perfusion.The traditional approach to traumatic shock with aggressive volume replacement has remained relatively unchanged for over 40 yrs, After achieving venous access, intravenous fluids were administered to accomplish immediate restoration of intravascular volume, During the late 1980s, clinical and laboratory studies questioned the logic and clinical appropriateness of traditional resuscitative approaches to the critically injured patient. Challenging aggressive blood pressure elevation during ongoing hemorrhage has resulted in a major paradigm shift in the approach to initial resuscitation in the past decade. This article addresses current controversies of initial resuscitation including the type, volume, and timing of intravenous fluids; the role of intentional hypotensive resuscitation; organization issues within trauma systems; and the resultant critical care implications of these changing practices.
Specific blood substitutes (hemoglobin-based) have passed safety studies and are now undergoing efficacy evaluation. These solutions have a long shelf life, do not require typing and cross-matching, are free of viral or bacterial contamination, appear to lack the immunosuppressive effects of blood, and have a much lower viscosity than blood. One third of the 10 million units of blood transfused in the United States each year are utilized in critically ill patients in an emergency setting. A safe substitute for blood should have a substantial impact on the way that we resuscitate critically ill patients. Also, the potential exists for use of these solutions as oxygen-therapeutic agents in increasing oxygen delivery to patients with ischemia (i.e., stroke, myocardial infarction, organ dysfunction).
To flourish in the New Economy, organizations need to rethink how they work. Critical care will have to reexamine its organizational design, which currently limits communication, coordination, and the full exploitation of information technology. Reengineering offers a comprehensive framework. for organizational redesign. I propose a reengineered ICU that involves changes in organizational structure, incentives, roles, and technology.
Wireless communication technologies are becoming more prevalent, more capable, and less expensive. Possible applications for wireless technologies in the delivery of health care are many and varied. The flexibility and convenience of sourcing or retrieving information without wires can improve the quality of care and reduce costs. An examination of today's applications and underlying technologies provides a basis for forecasting technology evolution and imagining the tools which might be available in the year 2010.
A blood monitor is a device that measures blood analytes without removing blood permanently from the patient and without additional cost for serial measurements. Blood monitors will be utilized in 2010 to provide blood gas values, electrolytes, and other values including, but not limited to, blood glucose, creatinine, blood urea nitrogen, lactate, coagulation studies, myocardial injury markers, and specific inflammatory response markers. These devices will require an arterial catheter and consist of: a) interchangeable modular sensor cassettes placed in series with the arterial catheter; b) a pump capable of withdrawing and reinfusing blood at specific rates and intervals; c) a mechanism for "wasting" a small aliquot of blood when a specific analysis renders the sample unfit for reinfusion; d) computer capability allowing for self-calibration and trouble shooting; e) ion-specific dilution cardiac output capability; f) cardiac output beat-by-beat computer capability; and g) the capability to display and integrate the information to the bedside medical information system.
Cardiac services are the biggest consumer of healthcare resources. Population statistics suggest that the aging population will need more cardiac care. This need will likely intensify the fiscal pressures on cardiac care providers. The emphasis is clearly on doing more with less, that is, minimizing the invasiveness of diagnostic, therapeutic, and monitoring procedures and accomplishing shorter hospital stay. Cardiac anesthesia and cardiac ICUs are under the same pressure. Analogous to other areas in cardiac care, cardiac anesthesia and intensive care medicine has experienced an explosion in technology, techniques, and pharmacotherapeutics. Just as minimally invasive cardiac surgery is challenging conventional cardiac surgery and catheter-based techniques, value-based goal-oriented cardiac anesthesia and new analgesic techniques are producing a paradigm shift from conventional high-dose narcotic anesthesia and prolonging postoperative ventilation. Unfortunately, our desire to introduce new technology has skipped ahead of the need to rigorously evaluate these techniques using simple clinical rules of evidence based medicine. The challenge for cardiac anesthesia and cardiac ICUs in the new millennium will be to adopt cost-effective technologies and strategies focused on patient care and to discard the often hyped and intensely fashionable but expensive technology. This article reviews the advances in cardiac surgery, cardiac anesthesia techniques, and the fast-track cardiac recovery models.
It's a digital world. Compact discs have made vinyl records of historical interest only We send millions of E-mails daily threatening the existence of letter carriers everywhere. Can we in cardiac critical care, if not all of health care, throw away paper charts in favor of an electronic medical record? In this chapter, we explore the history, opportunities, and obstacles ahead as we develop E-chart, an electronic medical record.
Ventilatory support of the critically injured patient remains a common challenge for the intensive care team. Recent advances related to the pathophysiology of acute respiratory distress syndrome (ARDS) has caused clinicians to reconsider ventilatory management and the selection of treatment end points, This review will summarize the issues related to ARDS pathophysiology, present current trends in traditional mechanical ventilation, discuss new modes of mechanical ventilation, and consider novel nonventilatory strategies.
Two principles govern the appropriate utilization of mechanical circulatory support (MCS). First, the choice of a device is a compromise between invasiveness and desired functional improvement. Second, the major goals of MCS are: a) to rest the myocardium; b) to maintain vital organ perfusion; and c) to support the patient to myocardial recovery or replacement. Specific criteria for device implantation exist but must be modified to reflect the comorbidities of the patient and the center-specific experience to enable timely institution of MCS, The postoperative care of mechanically assisted patients is also critical to the success of an RIGS program and has driven MCS teams to research and to learn new innovative ways of treating a variety of physiologic pathologies in the critical care arena. These lessons have improved care for all ICU patients. Placement of a device is only the beginning of a multidisciplinary therapy which requires a well-organized and specialized team to care for and to learn from these patients, MCS has added a new and higher level of support that the surgeon and intensivist can offer patients who previously had little hope. The timely implementation of these devices coupled with their improving: technology and increasing reliability, has begun to change the perception of MCS from a desperate measure to an effective therapeutic option that should be understood and utilized by those clinicians who manage the care of the critically ill.
Weaning from mechanical ventilation accounts for similar to 40% of the time that critically ill children with respiratory failure are on mechanical ventilator support. Because the weaning process is complex and nebulous, it is difficult to study. In the past decade, studies of weaning adult patients from mechanical ventilation have led to significant discoveries. Different methods of weaning can significantly shorten the duration of mechanical ventilator support, resulting in fewer complications and reduced hospital costs. Much less is known about the optimal weaning method for pediatric patients. The anatomic and physiologic differences between adults and children make it likely that much of the evidence from adult studies will not be applicable. This article reviews the current state of knowledge surrounding the process of weaning critically ill children from mechanical ventilator support.
Pharmacogenomics has the potential to not only revolutionize drug discovery and development, but it also has the potential to affect the may drugs are prescribed in the future. Genetics-based analyses will accelerate our understanding of disease mechanisms and will cause fundamental changes in the diagnosis, classification, and pharmacotherapy of disease. Uncovering genetic associations and gene functions may uncover more unknown related diseases and disease mechanisms, which can potentially widen therapeutic options. Unraveling the heterogeneity of disease mechanisms will lead to a better understanding of disease heterogeneity and patient variability in disease severity or disease progression. This knowledge will allow a better understanding of variation in response to pharmacotherapy and in the future, identification of new and potentially disease-modifying drug targets. This approach mill place a larger burden on education within the healthcare profession. Patients will have additional information and options about health and disease; they will have to make decisions now about therapy and life-style choices for future disease risks. Healthcare providers will be faced with new diagnostic standards, disease classifications, methods of choosing pharmacotherapy and providing counseling on pharmacogenetics, These new horizons in medicine will open new ethical and legal considerations that will significantly impact healthcare providers, patients, and payers.
Clinical studies have provided convincing evidence that early nutritional support benefits the metabolically stressed surgical patient, but the optimal route of substrate delivery, enteral or parenteral, continues to be debated. Optimal nutritional support following major torso trauma may best be provided via early enteral feeding. This article defines optimal nutrition following major torso trauma based on recently reported basic and clinical investigation, and describes a systematic method to deliver nutritional care in the ICU based on ongoing investigation. Part I reviews clinical evidence to support the conclusions that early nutrition following major torso trauma improves outcome, that the enteral route is preferred over the parenteral route, and that immune-enhancing enteral formulas should be used in selected patients. Part II describes an objective expert-evidence-consensus derived protocol strategy, including patient and formula selection, bedside surgical procedures, and nutrition management, in a multidisciplinary ICU environment. The specific mechanisms by which early enteral feeding benefits metabolically stressed trauma patients are not known, but it appears that the beneficial effects of traditional nutritional support can be amplified using specific nutrients that provide immune-enhancing effects. Additional investigation is needed and may provide insight to the role of the gastrointestinal tract in critical illness.
Advances in surgical and anesthetic technique for cardiac surgical patients have prompted some to question the need for postoperative intensive care. In the current healthcare environment, there is increasing influence over treatment decisions by third-party payers and government funding agencies. Care provision is increasingly being scrutinized as to process, outcomes, and costs. This article examines the process of care for cardiac surgical patients and provides a decision-making model aimed at defining the process of quality care, achieving best outcomes, and minimizing cost. Different care models are analyzed and compared, using a cost simulator.
Delivery of optimal care to critically ill trauma patients during resuscitation requires rapid, accurate, and comprehensive monitoring of several major subsystems. Fortunately, several advances in cardiac, pulmonary, and regional perfusion monitoring have been made over the last several years that are particularly helpful in these patients. Recent advances in pulmonary artery catheter technology now enable the clinician to monitor continuously the patient's cardiac output and oxygen transport status. Volumetric pulmonary artery catheters provide useful information regarding preload, contractility, and afterload not previously available. These techniques are helpful. in patients with multisystem involvement; extrinsic forces that may render the information derived from traditional pulmonary artery catheters unreliable can now be accounted for with the new technology. Estimating perfusion status at both the systemic and regional levels is now possible. Serial measurements of arterial lactate and base deficit during resuscitation can be used to assess the effects of therapy on systemic oxygen utilization and acid-base status. Gastric tonometry provides a clinical method of estimating intestinal perfusion; this technique provides useful prognostic and therapeutic information in trauma patients. Several advances have been made in respiratory monitoring in terms of oxygenation and ventilation. Simultaneous measurements of arterial and venous saturations allow continuous assessment of the intrapulmonary shunt fraction. New microprocessor-based pulmonary monitors can measure work of breathing; these and other techniques may help in titrating more precisely ventilatory support, and in making decisions regarding extubation from mechanical ventilation. However, the availability of the information from these monitors is not nearly as important as the clinician's understanding of what the data mean and how to apply this information in a beneficial fashion. Careful thought and application of basic physiologic principles, along with the additional information available from the newer monitoring techniques, are necessary to provide optimal care to these critically injured patients.
The acute respiratory distress syndrome is a significant cause of morbidity in critically ill children. While therapeutic interventions remain supportive, the management of evolving acute lung injury is often a controversial issue in the pediatric ICU. There has been significant progress in our understanding of the pathophysiology of acute lung injury and in our understanding of how lung injury is often amplified in the course of mechanical support, This understanding has led to a strategic shift in ventilation style principally geared to optimally recruiting and then maintaining end-expiratory lung volume, preventing the traumatic cycle of derecruitment-recruitment, and finally, limiting alveolar stretching during tidal inflation. We will review the evidence supporting this strategy from the data generated in both the animal laboratory and recently in adult clinical trials. We will discuss how tidal ventilation dynamics and conventional mode selection, patient positioning, adjuncts to conventional ventilation, high-frequency oscillatory ventilation, and permissive hypercapnia fit within this strategy.
Uncompensated (overt) or compensated (normotensive) shock results in oxygen debt accrual, a progenitor of cellular dysfunction and multiple organ system failure (MOSF), During reperfusion, oxygen free radicals are generated which are capable of causing extensive cellular injury through lipid perioxidation of cellular membranes and degradation of nucleic acids, In addition, generated reactive oxygen species attract and activate polymorphonuclear white blood cells and enhance their respiratory burst. The consequent oxidative stress amplifies the systemic hyperinflammation by inactivating proteases, thereby preventing the generation and release of counterregulatory anti-inflammatory cytokines and other mediators. The gastrointestinal tract has become a major focus in the pathophysiology of MOSF and has been identified as both the starter as well as the motor of this exasperating syndrome, associated intimately with ischemia-reperfusion injury, Strategies to prevent, or at least ameliorate the ravages of unfettered oxidative stress associated with ischemia reperfusion in the critically ill ICU patient must incorporate parenteral and enteral agents demonstrated in clinical and experimental studies to prevent or attenuate oxygen free radical injury, combined with adequate intravascular resuscitation and avoidance of vasopressors which vasoconstrict the splanchnic microcirculation.
In the past, healthcare providers have been allowed to create demand for medical services, then supply that demand in an open market. The reimbursement industry responded by denial of payment on the basis of retrospective audit. Yet, are continue to provide services with no assurance that any service will be funded, a self-fulfilling prophecy of doom. If we are to survive to see 2010, we must learn how to conserve and prioritize the use of increasingly scarce resources. As a political process, it is essential to match resources to need by regionalization at both the macro- and microallocation levels. There are powerful and well-financed forces that would slice up the pie for the benefit of those with the sharpest knife. If we expect the ship to stay afloat, we must become personally involved in bailing out the bilge. Our future outcome as advocated of good patient care is directly dependent on learning to play the political game better than we do now.
Coronary artery bypass graft (CABG) surgery and the subsequent postoperative ICU stay offer an important opportunity to explore some of the complexities of hospital and ICU benchmarking and patient outcome prediction. In this article, we first consider the definition of healthcare performance, discuss whether it can be "benchmarked" using outcomes data, and review the principles of risk-adjustment to allow for the interpretation of outcomes data. We then review the development, current status, and limitations of outcome prediction for the ICU and for CABG, including a discussion of the literature regarding outcome after cardiac surgery and models that predict outcome on admission to the ICU post CABG. Finally we assess the extent to which these outcome assessment models have helped or hindered improved delivery of care.
