Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography.

Objective: To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites.

Methods: Grading of Recommendations, Assessment, Development and Evaluation system was used to rank the "levels" of quality of evidence into high (A), moderate (B), or low (C) and to determine the "strength" of recommendations as either strong (strength class 1) or conditional/weak (strength class 2), thus generating six "grades" of recommendations (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation was used for all questions with clinically relevant outcomes.

Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part I: General Ultrasonography.

Objective: To establish evidence-based guidelines for the use of bedside ultrasound by intensivists and specialists in the ICU and equivalent care sites for diagnostic and therapeutic purposes for organs of the chest, abdomen, pelvis, neck, and extremities.

Methods: The Grading of Recommendations, Assessment, Development and Evaluation system was used to determine the strength of recommendations as either strong or conditional/weak and to rank the "levels" of quality of evidence into high (A), moderate (B), or low (C) and thus generating six "grades" of recommendation (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for all questions with clinically relevant outcomes.

Making the financial case for a surgeon-directed critical care ultrasound program.

Background: We sought to demonstrate that a well-staffed, surgeon-directed, critical care ultrasound program (CCUP) is financially sustainable and provides administrative and educational support for point-of-care ultrasound.

Methods: The CCUP provides a clinical service and training as well as conducts research. Initial costs, annual costs (C), revenue (R), and savings (S) were prospectively recorded.

Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database.

Background: Optimal management of adolescent trauma patients with blunt abdominal solid organ injury (SOI) remains controversial. The purpose of this study was to identify management differences in adolescents with SOI treated at adult trauma centers (ATC) versus pediatric trauma centers (PTC). We hypothesized that adolescents with SOI would undergo different treatment at ATC and PTC.

Injured adolescents, not just large children: difference in care and outcome between adult and pediatric trauma centers.

Adolescent injury victims receive care at adult trauma centers (ATCs) and pediatric trauma centers (PTCs). The purpose of this study was to identify care variations and their impact on the outcome of adolescent trauma patients treated at PTC versus ATC. We queried the Pennsylvania Trauma Systems Foundation database for trauma patients between 13 and 18 years of age from 2005 to 2010.

Blunt hollow viscus and mesenteric injury: still underrecognized.

Background: Despite the availability of more accurate imaging modalities, specifically multidetector computed tomography (MDCT), the diagnosis of non-ischemic (NI-) and ischemic (I-) blunt hollow viscus and mesenteric injury (BHVMI) remains challenging. We hypothesized that BHVMI can be still missed with newer generations of MDCT and that patients with I-BHVMI have a poorer outcome than those with NI-BHVMI.

Methods: We performed an eight-year retrospective review at a level 1 trauma center.

Postoperative complications: delirium.

Delirium is a common feature of the postoperative period, leading to increased morbidity and mortality and significant costs. Multiple factors predispose a patient to delirium in its hypoactive, hyperactive, or mixed forms. Tools have been validated for its quick and accurate identification to ensure timely and effective multidisciplinary intervention and treatment.

Academic time at a level 1 trauma center: no resident, no problem?

Background: Globally, the compliance of resident work-hour restrictions has no impact on trauma outcome. However, the effect of protected education time (PET), during which residents are unavailable to respond to trauma patients, has not been studied. We hypothesized that PET has no impact on the outcome of trauma patients.

Treatment of sepsis in the surgical intensive care unit.

Since the Surviving Sepsis Campaign Guidelines (SSG) were published in 2004, critical care physicians can readily access the evidence and current recommendations regarding management of patients with severe sepsis and septic shock. However, several issues including a potential conflict of interest in developing the guidelines were disclosed. There have also been dramatic changes in the management of sepsis, supported by high levels of evidence.

Ultrasound in the surgical intensive care unit.

Ultrasonography in the intensive care unit (ICU) has become a valuable tool for expeditiously, safely and effectively diagnosing and treating a myriad of conditions commonly encountered in this setting. Most surgeons are familiar with FAST (Focused Assessment with Sonography in Trauma) and can readily grasp the fundamentals of a limited or directed ultrasonographic exam. Thus, with appropriate training and practice, surgeons can utilize this tool in visualizing, characterizing and treating life-threatening conditions in their role as intensivists in the surgical ICU (SICU).

Beyond focused assessment with sonography for trauma: ultrasound creep in the trauma resuscitation area and beyond.

Purpose Of Review: The use of ultrasound for the management of the injured patient has expanded dramatically in the last decade. The focused assessment with sonography for trauma (FAST) has become one of the fundamental skills incorporated into the initial evaluation of the trauma patient. However, there are significant limitations of this diagnostic modality as initially described.

Posttraumatic contrast-induced acute kidney injury: minimal consequences or significant threat?

Background: Recent enthusiasm for the use of iodinated contrast media and progressive adaption of modern imaging techniques suggests an increased risk of contrast-induced acute kidney injury (CIAKI) in trauma patients. We hypothesized that CIAKI incidence would be higher than that previously reported.

Methods: A 1-year retrospective review of our prospective database was performed.

A survey of critical care training amongst surgical residents: will they be ready?

Background: Residents' duty-hour limitations and the trends towards closed-staffing for surgical critical care (SCC) have reshaped educational paradigms. No study has yet addressed the impact of these changes on resident SCC training. In our study, we investigated residents' experiences and perceptions of SCC education and practice.

Bedside ultrasound can safely eliminate the need for chest radiographs after central venous catheter placement: CVC sono in the surgical ICU (SICU).

Background: Real-time ultrasound guidance of central venous catheter (CVC)/peripherally inserted central catheter (PICC) insertion improves safety and efficacy. We hypothesized that a more robust ultrasound surveillance technique incorporating thoracic, vascular, and cardiac views-the CVC sono-would avoid the need for chest radiography to realize cost and efficiency gains.

Methods: We conducted a prospective data collection in a high-volume, urban, academic SICU.

Characterization of persistent hyperglycemia: what does it mean postinjury?

Background: Strict glycemic control has been shown to reduce both morbidity and mortality in critically ill surgical patients; however, overly aggressive management of hyperglycemia may also be associated with deleterious effects. We sought to characterize clinical outcomes associated with different levels of persistent hyperglycemia (PH) in a cohort of severely injured patients with trauma, when a strict glycemic control protocol (target glucose 80-110 mg/dL) was implemented.

Methods: Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in blunt injured adults with hemorrhagic shock.

Dissecting delays in trauma care using corporate lean six sigma methodology.

Objective: The Institute of Medicine has identified trauma center overcrowding as a crisis. We applied corporate Lean Six Sigma methodology to reduce overcrowding by quantifying patient dwell times in trauma resuscitation units (TRU) and to identify opportunities for reducing them.

Methods: TRU dwell time of all patients treated at a Level I trauma center were measured prospectively during a 3-month period (n = 1,184).