Seminars in respiratory and critical care medicine
-
Semin Respir Crit Care Med · Feb 2016
ReviewWho Should Be at the Bedside 24/7: Doctors, Families, Nurses?
Critical illness does not keep to regular, daytime business hours; we must provide high-quality care and support for intensive care unit (ICU) patients 24 hours per day, 7 days per week. Whether this mandates the presence of similar numbers and types of personnel throughout all hours of the day, however, has been the subject of much debate and substantial research. In this article, we review the available literature on the consequences of having three groups of care providers at a patient's bedside overnight: physicians, visitors, and nurses. ⋯ Uncertainties include whether outcomes are better when each nurse is assigned only one patient (or, more generally, the optimal patient:nurse ratio), who these nurses should be (e.g., registered nurses vs. other personnel), and what their roles should entail (e.g., managing ventilators). As such, we cannot yet identify the optimal overnight nurse staffing strategy. What is clear is that the critical care community needs more and better data to further define these aspects of the relationship between ICU structure and ICU outcomes.
-
Semin Respir Crit Care Med · Feb 2016
ReviewTools of the Trade: Point-of-Care Ultrasonography as a Stethoscope.
Since the advent of portable ultrasonography machines, many providers, including intensivists and pulmonologists, have been trained in point-of-care ultrasonography. When point-of-care ultrasonography is performed with focused clinical question and goal in mind, it serves as a valuable adjunct to physical examination and facilitates patient care and disease management. Its clinical application is now wider than that of a stethoscope in the intensive care unit where the noise level is high. ⋯ In addition, recent studies on the use of multiorgan system point-of-care ultrasonography in diagnoses and management of acutely ill patients are described. As new clinical applications have been identified, a conventional approach to the critical illness must be modified to a new approach that incorporates ultrasonographic information. Clinicians should not only be trained in image acquisition and interpretation but also be up to date on the new ultrasonography-guided diagnosis, therapy, and management.
-
Semin Respir Crit Care Med · Feb 2016
ReviewHow Cool It Is: Targeted Temperature Management for Brain Protection Post-Cardiac Arrest.
Neurological recovery often determines outcome in patients resuscitated after cardiac arrest. Temperature control as a neuroprotective strategy has become standard of care. The first randomized trials showing improved neurological outcomes in patients treated with hypothermia with a target temperature of 33°C over a decade ago led to the inclusion of this intervention in practice guidelines and the broad adoption of hypothermia protocols across the world. ⋯ However, the optimal temperature target, timing of induction, duration of temperature control, and speed of rewarming are unclear. Similarly, the value of targeted temperature management in cases of in-hospital arrest and non-shockable rhythms is unknown. This article reviews the neuroprotective mechanisms of hypothermia, the evidence supporting targeted temperature management after cardiac resuscitation, areas of persistent uncertainty and controversy, and future research directions.
-
Semin Respir Crit Care Med · Feb 2016
ReviewToo Little Oxygen: Ventilation, Prone Positioning, and Extracorporeal Membrane Oxygenation for Severe Hypoxemia.
Severe hypoxemia is associated with untoward outcomes in acute respiratory distress syndrome patients. Nevertheless, in and of itself, correction of hypoxemia is not an adequate surrogate outcome for mortality and clear evidence-based targets for correction of hypoxemia remain to be determined. ⋯ Notable progress in care includes further refinements in mechanical ventilation, consideration of salutatory effects of early prone positioning and neuromuscular blockade, and exploration of adjunctive extrapulmonary support with extracorporeal membrane oxygenation. This review focuses on three specific aspects: the evolving trend toward open lung ventilation, tempered by the recent cautionary experience with high-frequency oscillation ventilation; the evolution of prone positioning as a treatment for the most hypoxemic patients; and the continued future promise of extracorporeal support as a true rescue therapy.
-
Semin Respir Crit Care Med · Feb 2016
ReviewToo Much Oxygen: Hyperoxia and Oxygen Management in Mechanically Ventilated Patients.
Hyperoxia, or excess oxygen supplementation, prevails in the intensive care unit (ICU) without a beneficial effect and, in some instances, may cause harm. Recent interest and surge in clinical studies in mechanically ventilated critically ill patients has brought this to the attention of clinicians and researchers. Hyperoxia can cause alveolar injury, pulmonary edema, and subsequent systemic inflammatory response and is known to augment ventilator-associated lung injury. ⋯ However, this problem is often overlooked. The use of periodic reminders and decision support may facilitate implementation of more precise oxygen titration at the bedside of critically ill patients. For implementing practice change, studies involving education and guidance of all health care staff involved in oxygen management are critical.