Objective. To provide a general descriptive account and review of the literature regarding the use of dexmedetomidine for sedation during fiberoptic bronchscopic (FOB) intubation. Data Source. A computerized bibliographic search of the literature regarding dexmedetomidine for FOB intubation. Main Results. Several anecdotal reports describe the use of dexmedetomidine to provide sedation during FOB intubation. Additionally, 7 prospective trials were identified. These prospective trials demonstrate the efficacy of dexmedetomidine in providing sedation during FOB intubation of the airway. In a placebo-controlled trial with midazolam used as the rescue medication, dexmedetomidine decreased the need for rescue midazolam and the combination of the 2 agents was better than midazolam alone. When compared with propofol, there were fewer airway and respiratory issues as well as improved patient comfort with dexmedetomidine. Although dexmedetomidine was found to be better than fentanyl, there was a higher incidence of adverse hemodynamic effects. Although dexmedetomidine was inferior to remifentanil, the study used a lower loading dose of dexmedetomidine than other studies (0.4 vs 1.0 µg/kg). Despite its efficacy, adverse hemodynamic effects were noted. In many cases, the incidence was higher with dexmedetomidine than the comparator agent. In all reported cases, these were corrected with the administration of atropine, a vasoactive medication (phenylephrine or ephedrine), and/or fluid. Conclusions. The present literature clearly reports the advantage of using dexmedetomidine to decrease the risk of adverse respiratory effects, including airway obstruction. However, there remain unanswered questions about dexmedetomidine for sedation during FOB intubation of the airway including dosing regimens for both the bolus and infusion, techniques to limit the potential for adverse hemodynamic effects, and whether it should be the sole agent or used in combination with another agent.
In an acute event, the diagnosis of malignant hyperthermia (MH) in patients in the ICU can be challenging. Initial presentation may be attributed to a gamut of causes, making the diagnosis complicated. This example is the case of a 46-year-old African American man who was admitted to the Stroke Service and intubated for respiratory distress. To facilitate intubation, he was given etomidate and succinylcholine. Within an hour, a sustained increase in arterial carbon dioxide concentration, rhabdomyolysis, and later on, hyperthermia, developed. He was started on broad-spectrum antibiotics, aggressive fluid hydration, and mechanical ventilation. He had had one previous uneventful anesthesia exposure and he denied having any family member having anesthesia complications. With a very convoluted presentation, a high degree of suspicion for MH warranted appropriate treatment to avoid significant morbidity and/or mortality. Moreover, until the diagnosis is confirmed, education regarding the disease process to patients and their family members is as vital as the treatment itself. The main objective of this case is to present a diagnostic dilemma in a probable MH patient who is in a state of shock in the ICU.
High anion gap metabolic acidosis (HAGMA) is a frequently observed laboratory finding in critically ill patients. Usually HAGMA occurs as a result of common disease processes. However, rare diseases often manifest themselves by mimicking common disease processes with subtle differences, occasionally making the diagnosis challenging. In the following case, the metabolic workup of a patient revealed HAGMA acidosis. After ruling out the usual causes, diligent investigation by our team of subtle laboratory clues revealed a rare cause for HAGMA.
Management of chronic pain patients presents a unique challenge to critical care providers. These patients may have significant opioid tolerance and exhibit signs of opioid-induced hyperalgesia. Mechanical ventilation, hemodynamic instability and cognitive impairment further complicate the accurate assessment of pain and efficacy of treatment. This review will examine core topics such as management of opioid-tolerant patients, drug interactions, and implantable therapies that pose problems to critical care providers.
Background. In 2006, the Vanderbilt Heart and Vascular Institute significantly expanded its clinical operations, in part through the acquisition of cardiology, cardiac surgical, and vascular surgical practices. This article will describe the integration that has taken place since clinical expansion, the outcomes achieved, and discussion of key drivers of success. Results. In 2011, Vanderbilt Heart and Vascular Institute University HealthSystem Consortium (UHC) data show 3863 cardiology cases in addition to 1201 patients who underwent cardiac surgery. Compared with 2005, the 2011 cardiac surgical volume increased by 267%. Among the cardiology/cardiac surgical patients, the UHC mean ICU days were 2.9/3.37 in 2008 and 2.72/3.05 days in 2011. The UHC mortality index was .95/.90 in 2008 and .72/.53 in 2011 for cardiology and cardiac surgery, respectively. Key benchmarks for blood stream infections, ventilator-associated pneumonia, and urinary tract infections have all improved since September 2006. Quality improvement initiatives included vent bundle, identification of high-risk ventilator-associated pneumonia, glucose control, falls, Foley catheter education, and central line maintenance education to name a few. Conclusion. The Vanderbilt experience shows one way to integrate practices that can help in improving patient outcomes and therefore increase value. Future work will need to address how this relates to institutional cost and translates into the bundled payment world.
Calcium channel blocker overdose is one of the leading causes of overdose death among cardiovascular medications. We present a patient with the highest reported dose of amlodipine ingestion in combination pill. She was asymptomatic initially and soon became hypotensive and obtunded. She was intubated for airway protection, gastric lavage was done, and activated charcoal was given. She was resuscitated with 4L 0.9% normal saline, calcium chloride, glucagon, insulin, and glucose infusions. Her hypotension worsened necessitating use of norepinephrine 200 µg/min, phenylephrine 200 µg/min, dopamine 50 µg/kg/min, and vasopressin 0.06 U/min concurrently. She continued to improve and was weaned off vasopressors and mechanical ventilation. Few cases of extremely high-dose ingestion have been reported. Patients may be normotensive but rapidly progress to shock depending on ingested dose. High doses are associated with shock, bradycardia, pulmonary edema, renal failure, and heart failure. The primary goal is to maintain adequate circulation. Therapy includes intravenous fluids, insulin, glucagon, vasopressors, calcium infusion, and atropine. Based on our patient and a review of literature, we conclude that patients with near-fatal calcium channel blocker ingestion usually have good outcomes with appropriate use of high-dose vasopressors, glucagon, and insulin.
Objective. Acupuncture has been shown to decrease opioid requirements and respiratory distress in selected patients, and it may be helpful as an adjunctive therapy to sedatives and analgesics in the ICU. This preliminary study investigated the acceptance and feasibility of acupuncture in the ICU. Design. Forty-eight patients in a 12-bed medical–surgical ICU at Cedars-Sinai Medical Center who met eligibility criteria were offered the opportunity to receive free-of-charge daily acupuncture treatments during their time in the ICU. Primary endpoints were percentage of patients offered acupuncture who accepted treatment, the percentage of eligible days acupuncture therapy was received, and the incidence of adverse events related to acupuncture treatment. Main Results. Of the 48 patients who were eligible and offered acupuncture therapy, 20 (41%) patients enrolled in the study with an average age of 56 years (range = 18-91 years). The median and average number of days which patients received acupuncture was 2 and 3, respectively (range = 0-11 days), and a majority of patients (13/20) received acupuncture for each of the days for which they were eligible. One patient reported dizziness, which resolved spontaneously and was not associated with hemodynamic changes. No other adverse effects occurred in a total of 64 acupuncture treatments. Conclusions. This preliminary study demonstrates that acupuncture therapy in the ICU is a feasible treatment modality. Further clinical trials are warranted to determine the efficacy of acupuncture therapy as an adjunct to sedative and analgesics in critically ill patients.
Background. There are no rigid guidelines for the management of primary spontaneous pneumothorax. Although there seems to be a consensus between several medical societies regarding the management of an asymptomatic small pneumothorax, the approach toward a moderate to large symptomatic primary spontaneous pneumothorax is unclear and is not substantiated by well-designed research studies. Objectives. Our aim is to shed some light on the role of observation alone in the setting of moderate to large primary spontaneous pneumothorax and to report the different medical societies’ views on the treatment of a primary spontaneous pneumothorax. Case report. We report a case of a 26-year-old man who presented to our emergency department with shortness of breath and was found to have a symptomatic moderate-size pneumothorax that was successfully treated with oxygen therapy and supportive care. Conclusion. We hope that this case will stimulate further research in the field of primary spontaneous pneumothorax management advocating for simple observation and oxygen therapy.
The diagnosis of acute pancreatitis requires clinical, biochemical, and occasionally imaging information. Biochemical criteria include serum lipase levels, which are considered both sensitive and specific for the diagnosis of acute pancreatitis. Patients with diabetic ketoacidosis often have abdominal pain that may be related to the ongoing metabolic derangement or to precipitating intra-abdominal pathology. The pain severity in diabetic ketoacidosis helps determine whether abdominal disease should be further investigated. We present a patient with diabetic ketoacidosis and acute pancreatitis who had no significant elevation of amylase and lipase. The patient had abdominal pain that persisted despite ongoing treatment with intravenous insulin for ketoacidosis. The pain was initially located in the epigastrium and then migrated to the right lower quadrant. An abdominal computed tomography scan was obtained to exclude acute appendicitis, and this study revealed peripancreatic fluid consistent with acute pancreatitis that extended into the right lower quadrant anterior to the psoas muscle. A literature review of previous case reports and possible explanations for normal lipase levels are discussed. In conclusion, normal lipase levels do not exclude the diagnosis of acute pancreatitis and imaging criteria may be needed. It is also important to recognize that laboratory studies have limitations, and these should be taken into account when confirming a diagnosis.
Background. Central line–associated bloodstream infection (CLABSI) is the third most common nosocomial infection reported from the medical/surgical ICU setting. Rationale. The implementation of a central line protocol using a 3-part checklist would help ensure that all processes related to central line placement are executed for each line placement during the time it is used, thereby leading to improved outcomes. Physician assistants and nurses would be empowered to supervise the checklist and to stop or change the process if warranted. Methods. The intensivists performed a daily needs assessment of all central venous catheters (CVCs) in their respective ICUs. If the CVC was deemed unnecessary it was removed. The Surgical Continuum of Care comprised surgical physician assistants who made daily assessments of all CVCs among non-ICU inpatients. We hypothesized that these physician assistants would expedite the removal of CVCs among non-ICU inpatients. This would lead to a decreased number of central line days, and concomitant decrease in CLABSIs. Data collected were the standard data as used by the National Healthcare Safety Network. Results. From the year 2009 to 2012 the non-ICU lines decreased from 16 499 with a 3.3 CLABSI rate/1000 line days to 12 974 with a 0.85 CLABSI rate/1000 line days. The ICU line days decreased from 8190 with a 3.8 CLABSI rate/1000 line days to 5768 with 0.87 CLABSI rate/1000 line days. Conclusions. The number of CVCs used in the non-ICU patient areas has decreased with a concomitant decrease in CLABSI. The ICUs have seen a decrease in the number of CVC line/days and a concomitant decrease in CLABSI as well. Using a checklist and a clear standard policy in conjunction with a dedicated group of highly trained physician assistants and nurses has lead to a reduction in central line days and a reduction in CLABSI in the critical care areas as well as non-ICU areas.
Extracorporeal membrane oxygenation (ECMO), sometimes used interchangeably with extracorporeal life support, is a therapy that artificially supports pulmonary and/or cardiac organ systems. Venous blood is continuously withdrawn from a patient and passed across a membrane that can support both oxygenation and removal of carbon dioxide; blood is then reinfused back into the patient via venous or arterial access. A pump in the circuit can augment cardiac output, if necessary. Initial treatment with ECMO had discouraging outcomes, but recent experience with acute respiratory distress syndrome and the H1N1 influenza A pandemic in 2009 have led to a resurgence in popularity and additional research into this technique. At this time, treatment with ECMO is limited to highly specialized centers with well-trained practitioners. ECMO continues to be used primarily as a salvage technique in severe critical illness. This review will discuss the indications, complications, and types of ECMO. A guide to the clinical use of ECMO concludes the review.
Patients who become critically ill from sepsis, acute respiratory illness or other inflammatory processes often require intubation and mechanical ventilation to support respiratory function. The lungs are very susceptible to injury in these circumstances and may develop the syndromes of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Furthermore, patients in the operating room under anesthesia may also develop lung injury due to direct surgical trauma (pneumonectomy), aspiration, transfusion, shock, or allergic reaction. The approaches and techniques of mechanical ventilation continue to evolve with better understanding of the pathophysiology of ALI/ARDS. In this article, we will ( a) review the definitions of ALI/ARDS, ( b) define lung-protective ventilation and the etiologies of ventilator-associated lung injury, ( c) discuss rescue therapies for hypoxemic respiratory failure, and ( d) describe newer modes of mechanical ventilation in use both in the ICU and the operating room.
Teaching in the fast-paced, high-pressure environment of the ICU can be very demanding. Thus, the educator-intensivist must learn teaching strategies that are time-efficient, simple, and successful. In this article, we provide an overview of the current and relevant teaching theories and highlight potential obstacles and limitations to teaching in the ICU. In the second part, we discuss a sample of simple approaches to optimize the ICU-rotation curriculum as well as effective techniques to improve teaching, while not compromising quality of care.
Pulmonary hypertension is a hemodynamic problem that can result in grave morbidity and mortality, including right-sided heart failure and sudden death. The nature of the pulmonary circulation makes it highly interdependent with right ventricular function. Thus, the study of functional deterioration in pulmonary blood flow should always take into account the impact on right ventricular function, and vice versa. In this article, a comprehensive discussion of the pathophysiology, monitoring, and diagnosis is provided for the complicated disorder of pulmonary hypertension.
Background. Parenteral route is accepted for delivering nutrition when enteral feeding is not possible. Standardized premixed parenteral nutrition solution (SPNS) formulations are uniform in their characteristics and can be chosen based on the same nutrient calculations. We compared the feasibility of administering SPNS as an alternative to customized parenteral nutrition solution (CPNS) and calculate its cost implications. Methods. Retrospective review of 47 patients receiving CPNS at a tertiary care hospital ICU was performed and compared with SPNS formulations. The amounts of macro- and micronutrients (days 1, 3, 5, 7) were recorded and averaged to 2000-mL bag. These data were compared with the available premixed formulations and percentage differences were calculated. The costs and manpower for CPNS were obtained from our institutional central pharmacy. Results. The percentage difference for carbohydrates and proteins ranged from −1.0% to 2.9% and 5.8% to 9.0% with an average of 0.8% and 7.0%, respectively across all days. Since premixed micronutrients were only available in one formula, they were not easily comparable. The cost analysis showed an average savings of approximately $130 per parenteral nutrition bag. Conclusions. While macronutrients are quite comparable between formulations, any required micronutrients should be managed individually. SPNS has potential cost savings compared with CPNS when applied in the right setting.
Objective. To present the first case report of macrophage activation syndrome presenting as systemic inflammatory response syndrome secondary to rituximab. Design. Case report with review of the literature. Setting. Intensive care unit of university hospital. Patient. A 21-year-old female, who was diagnosed at age 19 with adult Still’s disease after having recurrent fevers, salmon-colored rash, polyarthralgias, and ferritin level of 24 000 ng/mL, was admitted to the hospital with fever, tachycardia, hypotension, leukocytosis, lethargy, and diarrhea. Intervention. The use of anakinra in the setting of systemic inflammatory response syndrome and macrophage activation syndrome. Results. The use of anakinra in patients with macrophage activation syndrome reduced inflammatory markers, lowered ferritin levels, and improved the patient’s symptoms as well as aided in recovery from cytokine-induced cardiomyopathy. Conclusions. This case illustrates this rare, but potentially life-threatening, side effect of rituximab and further adds to the growing literature that anakinra can be used in macrophage activation syndrome and suggests the possibility of other uses in the intensive care unit in the future.
