Sepsis may contribute to far more hospital readmissions than previously recognized — more than any other monitored condition. Recognition of this by federal and private payers could result in increased intensity of oversight of health teams’ care delivery for patients with sepsis. Hospital readmissions are squarely in the sights of the Centers for Medicare and Medicaid [… read more]
Every year, over a million people in the U.S. suffer respiratory failure requiring mechanical ventilation. They experience enormous catabolic stress, extended periods of inactivity, and usually go without their usual caloric intake. It’s no surprise that many are rendered profoundly debilitated by the experience. For many, this weakness and loss of muscle mass represents a second [… read more]
Medicare announced last week it will finally pay doctors for their time spent talking to patients about their end-of-life preferences, among the most important medical decisions most people will make. The decision overcomes years of setbacks brought about by Sarah Palin’s politicizing of the Affordable Care Act’s provision for end-of-life counseling as endorsing “death panels” of [… read more]
Doctors and nurses said patients and their families created the largest obstacles to end-of-life decision making in the ICU, in a large survey published in JAMA Internal Medicine. About 1,300 staff at 13 academic hospitals in Canada rated barriers to end-of-life goals of care on a 1-7 scale. Doctors and nurses considered the largest barriers [… read more]
Source: criticalecho.com Diaphragmatic Ultrasonography to Assess Readiness for Extubation By Muhammad Adrish, MD Weaning a patient from mechanical ventilation is a challenge that intensivists face routinely. Clinical examination and objective measurements like minute ventilation, respiratory rate, maximal inspiratory pressure, and ratio of respiratory rate to tidal volume have all been used with varying reported sensitivity [… read more]
People who survive critical illness often experience long-term cognitive impairment, even among those with normal or near-normal pre-hospital brain function. Cognitive impairment after critical illness is poorly understood; relatively few prospective clinical trials in critical care have followed patients after hospital discharge, and measuring cognitive impairment and determining its onset is difficult. Cognitive impairment reduces [… read more]
ICU-related Dysphagia and Swallowing Disorders More than 700,000 people develop respiratory failure requiring mechanical ventilation each year in the U.S. alone, and those that survive are at elevated risk for developing swallowing dysfunction. The aspiration syndromes that follow can be devastating, especially if not recognized and addressed early. Denver’s Madison Macht et al provide a clinical [… read more]
image: CUHK Early Tracheostomy Does Not Help in Large “TracMan” Trial More than 100,000 tracheostomies are performed worldwide each year for people requiring prolonged periods of mechanical ventilation. It’s generally agreed that to avoid damaging the trachea and throat, a tracheostomy should be placed within 3 weeks of mechanical ventilation. But prior to 3 weeks, [… read more]
“Trach Collar” Trials Beat Pressure Support for Long-Term Ventilator Weaning By Blair Westerly, MD Patients requiring prolonged mechanical ventilation linger in ICUs and long-term acute care hospitals for weeks, accounting for a significant portion of intensive care unit costs and often suffering serious complications while dependent on the ventilator. Despite this issue’s rising importance, the [… read more]
Knowing When, When Knowing Is Impossible By Paul C. McLean The child was her first, and there were complications and aggressive therapies from the start and for months. She was unaware that the medical team was coming to believe the baby would not survive, that aggressive treatments no longer served a therapeutic purpose and were [… read more]
Intubation for Out-of-Hospital Cardiac Arrest May Harm, Not Help by Blair Westerly, MD Out of hospital cardiac arrest is a major public-health problem, and despite advances in care, survival is still low. Improved survival has been associated with early CPR, rapid defibrillation, and integrated post cardiac arrest care, but pre-hospital “advanced airway management” (i.e., intubation [… read more]
(image: flickrCC) Half of patients transferred to long-term acute care facilities (LTACs) on prolonged mechanical ventilation will die within a year, according to a 2010 review. Only a small minority will ever go home without needing significant caregiver assistance. For those over age 65, the prognosis is even worse. It seems rude, or even cruel, [… read more]
This post was featured on KevinMD.com; an excerpt follows. “Full code” is the universal default status for patients who haven’t chosen otherwise. Yet I suspect most physicians believe this policy is wrong. We feel in our hearts we’re doing harm when we perform CPR on poor souls whose bodies are trying to naturally end their [… read more]
Daily interruption of sedation (daily awakening or sedation holidays) works like a charm to get patients off the ventilator, faster. After proving that a decade or so ago, practice-changers John Kress and William Schweickert have turned their attention to early mobilization as the next intervention that could help mechanically ventilated patients escape the ventilator faster. [… read more]
Many argue that as a limited resource serving unlimited needs, medical care is “rationed” by definition, and ICU resources (being more limited and expensive) are simply more overtly rationed. For example, in France, ICU admission is often denied to the very elderly critically ill, explicitly because of their age (this happens in the U.K., too, probably). In the U.S., [… read more]
Severe sepsis has had a 35-45% mortality rate in clinical trials. Gagan Kumar et al use national observational data to suggest that while population rates of severe sepsis are increasing, survival has likely improved, with mortality falling from 39% to 27%, 2000-2007. However, most of the new survivors are not going home, but rather to [… read more]
As Sancho et al point out here, there is a paucity of information available about tracheotomy in amyotrophic lateral sclerosis — when it’s best to perform the life-prolonging surgery, as well as what patients, families, and physicians can expect afterward. They followed 116 patients with ALS; 76 were recommended to receive tracheotomy when they could [… read more]
Obesity may impose extra burdens on critical care staff (think turning, transport, intubation and central line placement), but reviews suggest people with “ordinary” obesity (BMI 30-39) with have the same mortality from critical illness as overweight or healthy-weight people. In fact, obese people may have a survival advantage, despite possible longer durations of mechanical ventilation and ICU stays. But what about extreme obesity (BMI > [… read more]
Doctors are generally lousy at predicting death in terminally ill patients, and in ICU patients with indeterminate outcomes. Mortality prediction models have proliferated to improve our performance, but in the critical care literature, have mostly shown high predictive accuracy only at the tail ends of probability (high probability of survival or death). Siontis et al (led [… read more]
Adaptive support ventilation (ASV) has entered wide use based on its attractive premise: it’s patient-centered ventilation, adapting breath-by-breath to deliver precisely the right amount of pressure support to achieve a targeted minute ventilation. However, evidence for any superiority over conventional ventilator modes is limited to cardiac surgery patients who were extubated in ~6 hours regardless of [… read more]
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