ICU Director

First described more than 60 years ago, the open abdomen has now become a relatively common entity in surgical ICUs. Although the indications for an open abdomen have evolved since the original description of the damage control laparotomy, the goal remains to provide an unstable or critically ill patient time to correct their physiologic derangements. Temporary abdominal closure is thus used as a bridge to definitive repair and closure. Unfortunately, the open abdomen is associated with significant morbidity and mortality, and recent studies have suggested an overuse of the technique. Once the decision is made to proceed with an open abdomen, multiple options exist for temporary abdominal closure. The hope is to obtain definitive closure shortly thereafter in an attempt to reduce potential complications including intra-abdominal infection or enteroatmospheric fistula. Options for temporary closure range from the Bogotá bag to vacuum-assisted techniques; a combined technique of sequential fascial closure with vacuum assistance has recently been shown to result in 100% fascial approximation. In situations where fascial closure is unattainable, temporary coverage with a skin graft may be employed, followed by late abdominal closure via complex abdominal herniorrhaphy. Even using advanced methods such as component separation or a “pork sandwich” technique, the complication and recurrence rates remain high. A careful understanding of the indications, optimal management, and potential complications of the open abdomen is necessary to limit its overuse and ultimately reduce some of the challenges associated with it.

David J. Worhunsky

Gregory Magee

David A. Spain

Challenges in the Management of the Open Abdomen

开放性腹部管理的挑战

Since 2001, ventricular assist devices (VADs), total artificial hearts, and a growing number of devices have become increasingly more commonplace options to heart failure management and viable alternatives to heart transplantation. Cardiothoracic step-down and intensive care units will likely be managing more and more patients on mechanical circulation in the future. This review will briefly give an introduction to VAD function, types of VADs, the characteristics of VAD patients, and management issues in the ICU that may arise with these patients.

Ravi V. Joshi

Ventricular Assist Devices in the ICU

ICU中的心室辅助装置

Background. Although rapid response teams (RRTs) decrease in-house cardiac arrests, significant debate exists surrounding their impact on patient outcomes. We have implemented the continuum of care (CoC) model for the surgical services in our center as a novel approach to patient care. Methods. This study was designed to assess the utilization of RRT resources and cardiac arrests between RRT and CoC coverage. Results. Whereas hospital-wide RRT activations increased in incidence from 2007 to 2010 by 45%, CoC patients experienced steadily decreasing percentage of total RRT activations. Rapid response triggers that led to cardiac arrest under the CoC were 8% in comparison with 17% in the control group. Non-CoC model/RRT activations increased dramatically from 0.3% to 1.5% of total admissions over 4 years whereas CoC RRT activation rates minimally increased from 0.3% to 0.4% (events per total admission per year). Cardiac arrests occurred in 0.4% of non-CoC patients while only occurring in 0.03% of CoC patients, P &lt; .0001. Conclusion. The implementation of the CoC model reduces events requiring RRT activations, preserves continuity of care by closely following high-risk patients, and reduces cardiac arrests via proactive intervention by critical care specialists.

Garry Ritter

Tim Johnson

Heath Walden

Cordelia Sharma

Alison Corley

Thanjavur S. Ravikumar

Rafael Barrera

Comparison of Two Rapid Response Teams Models

两种快速反应团队模式的比较

C. Spencer Yost

Communication

沟通

Background. Over the past 5 to 10 years, there has been a change in the clinical practice of pediatric anesthesiology with a transition to the use of cuffed instead of uncuffed endotracheal tubes (ETTs) in infants and children. When such tubes are used in clinical practice, it is imperative to ensure that the intracuff pressure is ≤30 cm H 2 O. To date, there are limited data regarding techniques to ensure this practice. Methods. Following endotracheal intubation with a cuffed ETT, a stethoscope was placed in the sternal notch and continuous positive airway pressure of 20 to 25 cm H 2 O held. The fresh gas flow was increased as needed to achieve a gradual rise of the airway pressure. Using a syringe, air was added to the cuff until no air escape or leak was heard. The intracuff pressure was checked using a handheld manometer (Posey Cufflator Endotracheal Tube Inflator and Manometer, JT Posey Company, Arcadia, CA). Results. The cohort for the study included 200 patients ranging in age from 6 months to 18 years. In 5 patients (2.5%), there was no audible air leak noted following endotracheal inflation at a continuous positive airway pressure of 20 to 25 cm H 2 O. In these patients, the ETT was removed and the trachea was intubated with a 0.5-mm size smaller ETT. In the entire cohort of 200 patients, the intracuff pressure was 21 ± 4 cm H 2 O. The intracuff pressure was ≥30 cm H 2 O in 1 of 200 patients (0.5%). Conclusions. The current study demonstrates a simple, bedside maneuver that requires no additional equipment and is effective at ensuring a safe intracuff pressure in virtually all patients.

Joseph D. Tobias

Senthil Gopalakrishnan

Julie Rice

Kris R. Jatana

Charles Elmaraghy

Meredith Merz

Cuffed Endotracheal Tubes in Infants and Children

带套囊气管内导管在婴儿和儿童中的应用

Central line–associated bloodstream infections (CLABSIs) and ventilator-associated events (VAEs) are among the most prevalent and morbid health care–associated infections (HAIs) encountered in the ICU. The past decade has seen concerted efforts to reduce the cost of these infections, both fiscal and physical, but the evidence underlying these efforts varies in quality. Whereas the data supporting interventions to reduce CLABSI are robust and reproducible, the evidence for ventilator-associated pneumonia has suffered from inconsistencies. CLABSIs are well defined, may be confirmed by laboratory testing, and are amenable to active surveillance programs. In contrast, the clinical definition of ventilator-associated pneumonia lacks specificity and the diagnosis is confounded by inter-observer variability, thus complicating efforts to reduce its prevalence. In this context, we review recommendations for reducing these HAIs, and describe efforts to standardize surveillance definitions for VAE. These interventions are presented alongside our institution’s 5-year CLABSI and VAE data with notes on our changing practice over time. As intensivists, enacting current practice recommendations are among the best available measures to limit the incidence of HAIs in our ICUs.

Brad R. Cohn

Lee-lynn Chen

Central Line-Associated Bloodstream Infections and Ventilator-Associated Events in the Intensive Care Unit

重症监护病房中与中心静脉导管相关的血流感染和与呼吸机相关的事件

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.

Meghan Bhave

Marek Brzezinski

Teaching in the ICU

ICU教学

Final Exhale

最后一口气

Stress ulcer prophylaxis (SUP) with acid suppressive therapy is often inappropriately prescribed in the intensive care setting. Acid suppressive therapy, including proton pump inhibitors and histamine-2 receptor antagonists, has been associated with adverse effects, including increased risk of nosocomial infections. Reduction in the rate of inappropriate use of SUP may mitigate the risk of medication adverse effects and unnecessary health care costs. Our interdisciplinary team executed a bundled quality improvement initiative to reduce inappropriate use of SUP in the ICU, which included ( a) developing evidence-based clinical practice guidelines for use of SUP, ( b) implementing these clinical guidelines with an education intervention targeting ICU health care providers, and ( c) determining provider attitudes regarding SUP use before and after implementation of the bundled initiative. Within 1 month following implementation, inappropriate SUP (per patient hospital day) decreased from 19% to 6.6% ( P = .002). Our multidisciplinary bundled quality improvement initiative reduced inappropriate use of SUP. The program was successfully integrated into the pharmacists’ workflow, thus yielding a sustainable impact on SUP use.

Noelle de Leon

Suzanne Sharpton

Cindy Burg

A. Kendall Gross

Fanny Li

Ashley Thompson

Robin Kobayashi

Sherilyn J VanOsdol

Candy Tsourounis

Chelsea Tasaka

Charlotte Garwood

Lynne Bekeart

Stephanie Rennke

The Development and Implementation of a Bundled Quality Improvement Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis

减少不适当压力性溃疡预防的捆绑式质量改进措施的发展与实施

Objective. To assess the cost implications of changing the ICU staffing model from a mandatory 24-hour in-house critical care specialist presence to a 16-hour coverage model with external supervision. Design. A pre–post comparison was undertaken among the prospectively assessed cohorts of patients admitted to our surgical ICU over a period of 3 years. Our data were stratified by case mixed index. Costs were modeled using a generalized linear model with log-link and gamma-distributed errors. Setting. Tertiary medical facility. Patients. All patients admitted to the adult surgical intensive care unit during the study period of June 2007 to April 2013. Intervention. Changing the ICU staffing model from a mandatory 24/7 in-house critical care specialist presence to a 16/7 model with robotic rounding in off hours. Results. A total cost model was calculated and evaluated. Total cost estimates of hospitalization were calculated for each patient. Length of stay and mortality were evaluated. Adjusted mean total cost estimates per case were 29% lower in the postimplementation period relative to the preimplementation period. Mean net revenue increased by 367% in the postimplementation period relative to the preimplementation period. Billing charges increased by more than 70% and billing collections increased by more than 40% with the new model. Length of stay was reduced by 33% with the 16-hour model versus the preimplementation time frame and maintained at the lower level during the measurement period. Mortality rate was 59% lower in the postperiod relative to the preperiod. Demand analysis for surgical ICU service, length of stay cost and capacity issues improved. Conclusions. We found that a 16-hour ICU that incorporates robotic rounding, without per diem intensivists, reduces length of stay, mortality, cost estimates, and actual costs. We have also shown an increase in mean net revenue and billing collections. The cost of introducing this staffing model has the potential to favorably impact overall costs. In this study, the 16-hour critical care service model performed favorably both in terms of quality and cost. Clinical implications. This model increases total savings generated for such patients in smaller ICUs, especially ones that predominantly care for lower acuity patients. Critical care interventions are expensive and have a narrow safety margin. It is essential to develop structured and validated approaches to study the delivery of this resource.

Publication Information	Publisher: SAGE Publications Inc.，Publishing cycle: ，Journal Type: journal，Open Access Journals: No
Basic data	Year of publication: 2010，Proportion of original research papers: ，Self Citation Rate:， Gold OA Rate:

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