Evolution of the intensive care unit as a clinical center and critical care medicine as a discipline.

This article discusses the history of the ICU and critical care medicine (CCM). It also discusses the certification of critical care nurses and allied health professionals, as well as CCM societies and congresses, education and board certification, evidence-based CCM, research and publications, and future challenges to the field.

New aspects on critical care medicine training.

Recently, three fundamental changes have been introduced in medical education, all of particular importance to critical care medicine: (1) clinical teaching and medical practice now emphasize evidence-based medicine, (2) patient safety aspects are increasingly stressed, and (3) use of simulation in medical training is spreading rapidly. In 1999, the disturbingly high frequency of life-threatening or even lethal medical complications was emphasized by the Institute of Medicine in the book To Err Is Human. The Institute of Medicine recommended establishing interdisciplinary team training programs incorporating efficient methods such as simulation.

Guidelines for critical care medicine training and continuing medical education.

Objective: Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care.

Participants: A multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine.

Cerebral blood flow and metabolism after cardiopulmonary resuscitation. A pathophysiologic and prognostic positron emission tomography pilot study.

Background: Prolonged coma is not an uncommon clinical problem following resuscitation from cardiac arrest. Early and precise prediction of outcome is highly desirable for ethical and economical reasons. The aims of this study were to use positron emission tomography (PET) to investigate the regional dynamic changes of cerebral blood flow and metabolism during the early period after cardiopulmonary resuscitation (CPR) in unconscious patients and to evaluate if PET may be a potential prognostic evaluator.

Simulation-based training at the University of Pittsburgh.

The following article reviews the experience of using human simulators for medical education at the University of Pittsburgh in the Department of Anesthesiology and Critical Care Medicine. The intent of the authors is to provide the reader with an overview of 1) what human simulators can do, 2) the components of a simulation training facility, 3) some of the economic considerations in operating a simulation training facility, and 4) how this centre is made use of.

Intra-aortic administration of epinephrine above aortic occlusion does not alter outcome of experimental cardiopulmonary resuscitation.

Intra-aortic balloon occlusion during experimental cardiopulmonary resuscitation (CPR) improves coronary perfusion pressure and resuscitability and provides unique access to the central circulation. It has been hypothesized that administration of epinephrine into the aortic arch in combination with aortic occlusion would further improve haemodynamics during CPR, resuscitability and 24 h survival. In 16 anaesthetised dogs intravascular catheters were placed for hemodynamic and blood gas monitoring.

Improving the request process to increase family consent for organ donation.

The greatest impediment to organ donation is refusal of family consent. This study examined the impact of 3 modifiable elements of the donation request on family consent rates: (1) decoupling (i.e.

Future directions for resuscitation research. V. Ultra-advanced life support.

Standard external cardiopulmonary resuscitation (SECPR) frequently produces very low perfusion pressures, which are inadequate to achieve restoration of spontaneous circulation (ROSC) and intact survival, particularly when the heart is diseased. Ultra-advanced life support (UALS) techniques may allow support of vital organ systems until either the heart recovers or cardiac repair or replacement is performed. Closed-chest emergency cardiopulmonary bypass (CPB) provides control of blood flow, pressure, composition and temperature, but has so far been applied relatively late.

Future directions for resuscitation research. I. Advanced airway control measures.

The efficacy of 'basic' airway control without equipment, using the combination of backward tilt of the head, forward displacement of the mandible, and separation of lips and teeth (i.e. the triple airway maneuver) has been well established.

Resuscitation from severe brain trauma.

Severe traumatic brain injuries are extremely heterogeneous. At least seven of the secondary derangements in the brain that have been identified as occurring after most traumatic brain injuries also occur after cardiac arrest. These secondary derangements include posttraumatic brain ischemia.

Systemic perfusion pressure and blood flow before and after administration of epinephrine during experimental cardiopulmonary resuscitation.

Objectives: To evaluate instantaneous blood flow variations in the compression and relaxation phases of cardiopulmonary resuscitation (CPR) and the effect of epinephrine administration.

Design: Prospective, randomized, controlled trial.

Setting: Experimental laboratory in a university hospital.

Intensive care for critically ill elderly: mortality, costs, and quality of life. Review of the literature.

The literature on outcomes of intensive care for the elderly with regard to intensive care unit utilization, mortality, hospital costs and charges, and quality of life after intensive care were reviewed. Publications in the English literature, which evaluated intensive care and included elderly populations, were obtained from review of Index Medicus and MEDLINE. We conclude that age alone is not an acceptable predictor of critical illness with regard to mortality and quality of life of survivors.

Blood flow and perfusion pressure during open-chest versus closed-chest cardiopulmonary resuscitation in pigs.

Objective: To evaluate the blood flow and perfusion pressure differences observed during open- vs. closed-chest cardiopulmonary resuscitation (CPR), including the effects of epinephrine and sodium bicarbonate administration.

Design: Prospective, randomized, controlled trial.

Teaching medical students complex cognitive skills in the intensive care unit.

Objective: To determine if fourth-year medical students can learn the high-level cognitive skills needed to manage critically ill patients during a critical care medicine elective designed in accordance with established educational principles.

Design: Students were randomly assigned to take one of two examinations with ten short essay questions to complete on the initial day. After the elective, students completed the other examination in a crossover design.

Long-term outcome of critically ill elderly patients requiring intensive care.

Objective: To evaluate the long-term mortality and morbidity of critically ill elderly patients requiring intensive care.

Design: Prospective comparison of outcome of critically ill patients aged 75 years and older with patients aged 65 to 74 years.

Patients: Critically ill patients aged 65 years and older who required intensive care and who were recruited during a 3-month period.

History of organ donation by patients with cardiac death.

When successful solid organ transplantation was initiated almost 40 years ago, its current success rate was not anticipated. But continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, but also from using organs from different sources.