Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care.

Objectives: To describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level.

Participants: A multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM).

Data Sources And Synthesis: Relevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts.

A model for technology assessment as applied to closed loop infusion systems. Technology Assessment Task Force of the Society of Critical Care Medicine.

Objectives: To test a model for the assessment of critical care technology on closed loop infusion control, a technology that is in its early stages of development and testing on human subjects.

Data Sources: A computer-assisted search of the English language literature and reviews of the gathered data by experts in the field of closed loop infusion control systems.

Study Selection: Studies relating to closed loop infusion control that addressed one or more of the questions contained in our technology assessment template were analyzed.

Regionalization of critical care medicine: task force report of the American College of Critical Care Medicine.

Objectives: To review the existing literature and task force opinions on regionalization of critical care services, and to synthesize a judgement on possible costs, benefits, disadvantages, and strategies.

Data Sources: Pertinent literature in the English language.

Study Selection: One hundred forty-six English language papers were studied to determine possible ramifications of regionalization of critical care or other similar services.

MRI protocol for critically ill patients.

BACKGROUND Ventilators compatible with magnetic resonance imaging machines are not universally available. However, the lack of such equipment should not preclude magnetic resonance imaging. We have developed a method by which a critically ill patient requiring mechanical ventilation can safely undergo such imaging without compatible equipment.

Outcome of insulin-treated diabetics receiving epinephrine during cardiac arrest.

The purpose of this study was to determine the effects of epinephrine in insulin-treated diabetics (DM) compared with nondiabetic (ND) controls during cardiopulmonary resuscitation (CPR). A retrospective analysis from a multicenter study of out-of-hospital cardiac arrest included 62 DM and 1,151 ND. Outcome parameters included return of spontaneous circulation (ROSC), blood pressure (BP), emergency department admissions (EDA), hospital admissions (HA), and hospital discharge (DC).

Agreement between paramedic-estimated weights and subsequent hospital measurements in adults with out-of-hospital cardiac arrest.

Objective: To assess the accuracy of paramedic estimates of adult body weights in cardiac arrest cases.

Hypothesis: Paramedics could accurately estimate the weights of out-of-hospital cardiac arrest patients.

Design: Retrospective data analysis of a 15-month, multicenter study involving nontraumatic out-of-hospital cardiac arrest patients.

Effect of first-responder automated defibrillation on time to therapeutic interventions during out-of-hospital cardiac arrest. The Multicenter High Dose Epinephrine Study Group.

Study Objectives: The effect of automated defibrillation provided by basic emergency medical technician (EMT) first-responder units on the time intervals to other critical interventions in the management of out-of-hospital cardiac arrests is unknown. The purpose of this study was to define and compare elapsed time intervals to basic CPR, paramedic arrival, initial countershock, endotracheal intubation, IV access, and initial adrenergic drug therapy in first-responder automated defibrillation/paramedic versus basic EMT/paramedic emergency medical services systems.

Design: Prospectively collected data from a 15-month multicenter study of out-of-hospital, nontraumatic cardiac arrests were analyzed.

Initial countershock in the treatment of asystole.

Background: Routine provision of defibrillatory countershock (CS) in the initial management of asystolic cardiac arrest has been advocated because certain cases of ventricular fibrillation (VF) may present as asystole (AS).

Objective: To determine the value of initial CS versus endotracheal intubation and pharmacologic therapy alone in the treatment of asystolic cardiac arrest.

Design/participants: A retrospective analysis of data collected prospectively during a multicenter study of out-of-hospital cardiac arrest.

Regionalization and categorization of critical care services.

Regionalized systems of care match the medical needs of individual patients to available resources. Hospitals are categorized based on their personnel and technologic resources. Triage guidelines, based on severity of disease, are developed to link patient types to hospital categorization levels.

In-hospital cardiac arrest.

Patients who suffer an in-hospital cardiac arrest represent a neglected and underutilized resource for resuscitation research. There exists an unwritten, but widely held, belief among resuscitation researchers that the in-hospital arrest population is unsuitable for resuscitation research because it is composed mostly of patients whose cardiac arrest is the terminal event of a fatal illness. Despite the large numbers of hospitalized patients on whom cardiac resuscitation is attempted each year, there are few reports and even less true research devoted to this clinical problem.

A nurse-directed protocol using pulse oximetry to wean mechanically ventilated patients from toxic oxygen concentrations.

The usual method of weaning mechanically ventilated patients from high FIO2 in our ICU, in which housestaff ordered all ventilator changes in an unstandardized manner (control group), was compared to a nurse-directed protocol that used a single arterial blood gas (ABG) analysis and multiple pulse oximetry measurements. The protocol required an ABG to be obtained upon the initiation of intubation/mechanical ventilation, followed by pulse oximetry measurements obtained in accordance with a standardized timetable. Decreases in FIO2 were guided by these results.

Effectiveness of a human monoclonal anti-endotoxin antibody (HA-1A) in gram-negative sepsis: relationship to endotoxin and cytokine levels.

Gram-negative sepsis is caused by endotoxin-induced release of tumor necrosis factor (TNF) and other cytokines. HA-1A is a human monoclonal antibody that binds specifically to endotoxin. HA-1A should prevent death in endotoxemic patients and reduce serum levels of TNF and interleukin-6 (IL-6).

A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group.

Background: Experimental and uncontrolled clinical evidence suggests that intravenous epinephrine in doses higher than currently recommended may improve outcome after cardiac arrest. We conducted a prospective, multicenter study comparing standard-dose epinephrine with high-dose epinephrine in the management of cardiac arrest outside the hospital.

Methods: Adult patients were enrolled in the study if they remained in ventricular fibrillation, or if they had asystole or electromechanical dissociation, at the time the first drug was to be administered to treat the cardiac arrest.

Effect of ibuprofen in patients with severe sepsis: a randomized, double-blind, multicenter study. The Ibuprofen Study Group.

Objective: To evaluate the safety and physiologic actions of ibuprofen in patients with severe sepsis.

Design: Randomized, double-blind, placebo-controlled trial.

Setting: Three university hospital medical ICUs.

Relieving overcrowded emergency departments through ambulance diversion.

One city's solution to overcrowded emergency departments and a shortage of beds was the installation of an ambulance-diversion system, whereby ambulances carrying patients with relatively minor injuries were diverted, when necessary, from the city's busy emergency departments to less crowded ones in neighboring counties.

Glucocorticoid treatment does not improve neurological recovery following cardiac arrest. Brain Resuscitation Clinical Trial I Study Group.

Glucocorticoids are commonly given to patients with global brain ischemia, although their efficacy has not been proved. The database of the Brain Resuscitation Clinical Trial I, a multi-institutional study designed to evaluate the effect of thiopental sodium therapy on neurological outcome following brain ischemia, was used for a retrospective review of the effects of glucocorticoid treatment on neurological outcome after global brain ischemia. This study included 262 initially comatose cardiac arrest survivors who made no purposeful response to pain after restoration of spontaneous circulation.

Pharmacokinetics of a 3 mg/kg body weight loading dose of gentamicin or tobramycin in critically ill patients.

We evaluated the pharmacokinetics and adequacy of gentamicin or tobramycin after administration of a loading dose of 3 mg/kg body weight in 14 critically ill patients with presumed sepsis. Therapeutic blood levels after loading dose were obtained in 13 of the 14 patients. Measured volume of distribution, serum half-life, and elimination rate constant were significantly different from values calculated by using standard formulae.

Analysis of the effects of continuous on-line monitoring of mixed venous oxygen saturation on patient outcome and cost-effectiveness.

Continuous measurement of mixed venous oxygen saturation (Sv-O2) has recently been introduced as a monitoring and management technique in critical care patients. To determine the impact of Sv-O2 monitoring on patient management and cost-effectiveness, we conducted a prospective, randomized clinical trial of 99 consecutive patients receiving pulmonary artery (PA) catheters in the ICU. One group (n = 49) received an Edwards quadruple-lumen flow-directed PA catheter.

Bilateral optic atrophy after cardiac arrest in a patient with acute respiratory failure on positive pressure ventilation.

Bilateral blindness resulting from optic atrophy is an unusual complication following shock and cardio-respiratory arrest. This report describes a patient with acute respiratory failure due to pneumococcal pneumonia being treated with very high levels of positive end expiratory pressure who developed bilateral blindness following cardiac arrest. This unfortunate complication most likely resulted from increased intraocular pressure and low systemic perfusion pressure synergistically causing ischemia of the optic nerves.

Spontaneous dissection of the cervical internal carotid artery: correlation of arteriography, CT, and pathology.

Spontaneous dissection of the internal carotid artery is being recognized as a more frequent cause of acute neurologic deficit, particularly in young persons. Saccular pseudoaneurysm formation may be an associated finding, especially in the presence of tortuosity (coiling) of the cervical internal carotid artery. Of eight patients with nine vessels demonstrating internal carotid artery dissection on arteriography, pseudoaneurysms were found in five arteries.

Stabilization of patients prior to interhospital transfer.

With regionalization of specialized health care services, some patients must be transferred between hospital to receive needed care. The authors evaluated 100 transfers to their emergency department as to the adequacy of stabilization prior to transport. Problems were identified in the areas of communication (nine cases), oxygenation (two cases), cardiac monitoring (one case), intravenous lines (eight cases), airway (two cases), ventilation (one case), equipment and personnel accompanying the patient (one case), bladder catheterization (four cases), nasogastric suctioning (one case), radiographs (nine cases), and spinal immobilization (seven cases).