Profound Coronary Vasospasm Associated with Intraoperative Ketamine Administration: A Case Report.

We report a case of a 62-year-old woman with a decade-long history of atypical chest pain resulting in a largely negative cardiac workup, who developed significant angiographically demonstrated coronary vasospasm thought to be due to a small dose of intravenous ketamine. In patients with a history of atypical chest pain despite a reassuring cardiac evaluation, providers should carefully consider medications that may precipitate coronary vasospasm and be prepared to treat it accordingly.

Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units.

Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting.

Factors associated with 30- and 90-day mortality in intubations among critically ill patients.

Background: Emergency intubations are commonly associated with adverse events when performed in critically ill patients. A detailed look at intubation factors and their association with procedural success and mortality has yet to be fully conducted.

Methods: A total of 299 successive intubations at a tertiary Veteran Affair hospital were analyzed.

Variations in Code Team Composition During Different Times of Day and Week and by Level of Hospital Complexity.

Background: Previous data demonstrated lower survival rates of in-hospital cardiac arrests during nights and weekends compared to weekday daytime. This study aimed to evaluate variations of personnel attending to codes based on day/night/weekend conditions within the US Veterans Affairs (VA) system, as well as variations of personnel responsible for intubations during codes.

Methods: Hospital leaders were surveyed regarding code team membership, leadership, and intubations during four time periods (weekday daytime, weekday nighttime, weekend daytime, and weekend nighttime).

Defining Physiological Decompensation: An Expert Consensus and Retrospective Outcome Validation.

Objectives: Physiological decompensation of hospitalized patients is common and is associated with substantial morbidity and mortality. Research surrounding patient decompensation has been hampered by the absence of a robust definition of decompensation and lack of standardized clinical criteria with which to identify patients who have decompensated. We aimed to: 1) develop a consensus definition of physiological decompensation and 2) to develop clinical criteria to identify patients who have decompensated.

Mortality of Patients Requiring Escalation to Intensive Care within 24 Hours of Admission in a Mixed Medical-Surgical Population.

Objective: Delayed intensive care unit (ICU) admissions are associated with increased mortality. We present a retrospective study looking at whether indirect admissions to the ICU within 24 hours of hospital admission were associated with increased mortality.

Design: Retrospective cohort study SETTING: Mixed medical-surgical ICU at a large tertiary United States Veterans Affairs (VA) Hospital System POPULATION: The patients were a mix of medical and surgical patients.

Lactate Predicts Both Short- and Long-Term Mortality in Patients With and Without Sepsis.

Objective: To measure the relationship between lactate and mortality in hospital inpatients. Main outcomes of interest were 3-day, 30-day, and 1-year all-cause mortality.

Design: Retrospective cohort study, October 2011 to September 2013.

Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems.

Background: Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS.

The association of clinical frailty with outcomes of patients reviewed by rapid response teams: an international prospective observational cohort study.

Background: Frailty is a state of vulnerability to poor resolution of homeostasis after a stressor event and is strongly associated with adverse outcomes. Therefore, the assessment of frailty may be an essential part of evaluation in any healthcare encounter that might result in an escalation of care. The purpose of the study was to assess the frequency and association of frailty with clinical outcomes in patients subject to rapid response team (RRT) review.

Perioperative Surgical Home Reduces Rapid Response Calls to a Postoperative Surgical Ward: How Anesthesiologists Are Improving the Inpatient Safety Net.

Background: The Perioperative Surgical Home (PSH) is an anesthesiologist-led, coordinated care model that may improve patient experience and safety. We hypothesized that PSH will decrease activation of the rapid response system for surgical inpatients.

Methods: This retrospective study was performed at an academic Veterans Affairs hospital with a PSH.

A Novel Bedside-Focused Ward Surveillance and Response System.

Background: Rapid response systems (RRSs) have been universally adopted in much of the developed world; yet, despite broad implementation, their success has often been limited. Even with successful systems, there is a small body of evidence regarding effective organizational elements that are responsible for improved outcomes. New organizational processes were implemented that restructured the existing RRS, and the impact on the number of rapid response team (RRT) alerts, cardiac arrest, and mortality rates was evaluated.

Clinical outcomes of patients seen by Rapid Response Teams: A template for benchmarking international teams.

Aim: The study was developed to characterize short-term outcomes of deteriorating ward patients triggering a Rapid Response Team (RRT), and describe variability between hospitals or groups thereof.

Methods: We performed an international prospective study of Rapid Response Team (RRT) activity over a 7-day period in February 2014. Investigators at 51 acute hospitals across Australia, Denmark, the Netherlands, USA and United Kingdom collected data on all patients triggering RRT review concerning the nature, trigger and immediate outcome of RRT review.

Survival After Long-Term Residence in an Intensive Care Unit.

A higher mortality trend correlated with increased age and length of stay for medical and surgical patients in the intensive care unit.

Evaluating the Impact of Classroom Education on the Management of Septic Shock Using Human Patient Simulation.

Background: Classroom lectures are the mainstay of imparting knowledge in a structured manner and have the additional goals of stimulating critical thinking, lifelong learning, and improvements in patient care. The impact of lectures on patient care is difficult to examine in critical care because of the heterogeneity in patient conditions and personnel as well as confounders such as time pressure, interruptions, fatigue, and nonstandardized observation methods.

Methods: The critical care environment was recreated in a simulation laboratory using a high-fidelity mannequin simulator, where a mannequin simulator with a standardized script for septic shock was presented to trainees.

Understanding Decision Making in Critical Care.

Background: Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action.

Rationale: There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature.

A Rare Cause of Patient Movement Occurring During Carotid Surgery.

In this case, we report difficulty in the conduct of carotid surgery during an earthquake. With the epicenter >200 miles away, intraoperative movement was subtle and initially attributed to recovery from neuromuscular blockade. More significant seismic motion in a hospital is accompanied by additional challenges that are discussed.

Routine postoperative care of patients undergoing coronary artery bypass grafting on cardiopulmonary bypass.

The postoperative course of a patient undergoing cardiac surgery (CS) is dictated by a largely predictable set of interactions between disease-specific and therapeutic factors. ICU personnel need to quickly develop a detailed understanding of the patient's current status and how critical care resources can be used to promote further recovery and eventual independence from external support. The goal of this article is to describe a typical operative and postoperative course, with emphasis on the latter, and the diagnostic and therapeutic options necessary for the proper care of these patients.

Safer tracheostomy: a proposal for the routine use of an airway exchange catheter during tracheostomy.

In the United States, more than 100,000 tracheostomies are performed annually. Many patients undergoing tracheostomy are critically ill, making them higher risk surgical candidates. Fortunately, the loss of airway during the procedure is rare, but when it occurs, the outcome can be catastrophic.

Videos in clinical medicine: Laryngeal mask airway in medical emergencies.

This video demonstrates the placement of a laryngeal mask airway, an alternative airway device that is both efficacious and easy to place. The laryngeal mask airway is routinely used for patients receiving general anesthesia and, increasingly, in patient resuscitation.

Percutaneous tracheostomy at the bedside: 13 tips for improving safety and success.

We have developed a set of routines and practices in the course of performing a large series (n = 70) of percutaneous dilational tracheostomy (PDT). The 13 tips discussed in this review fall into 4 categories. System factors that facilitate training, patient safety, and avoidance of crises including the use of appropriate personnel, importance of timing, use of premedication, and the utility and content of a preprocedure briefing.