An algorithm for the sedation of patients with obstructive sleep apnea by non-anesthesiologists.

Objective: Patients with obstructive sleep apnea (OSA) are at risk for adverse events when moderate sedation is administered by nurse protocols (NAMS) under the guidance of non-anesthesiologists. An algorithm was applied for the appropriate section of patients to receive NAMS and the application of continuous positive airway pressure (CPAP).

Methods: An algorithm was developed for patients with OSA who were scheduled for gastroenterology, radiology, and cardiology procedures using NAMS.

Respiratory Physiology for the Anesthesiologist.

Respiratory function is fundamental in the practice of anesthesia. Knowledge of basic physiologic principles of respiration assists in the proper implementation of daily actions of induction and maintenance of general anesthesia, delivery of mechanical ventilation, discontinuation of mechanical and pharmacologic support, and return to the preoperative state. The current work provides a review of classic physiology and emphasizes features important to the anesthesiologist.

The physiologic basis for goal-directed hemodynamic and fluid therapy: the pivotal role of the venous circulation.

Purpose: Understanding cardiovascular physiology should help clinicians to understand the purpose of fluid and drug management during the perioperative period. The purpose of this narrative review is to describe the pivotal role of the venous circulation in goal-directed hemodynamic and fluid therapy.

Source: We selected relevant literature that examines the appropriateness of fluid therapy and pharmacologic interventions during the perioperative period.

Benefit of using a "bundled" consent for intensive care unit procedures as part of an early family meeting.

Purpose: Relatives of patients in the intensive care unit (ICU) are often dissatisfied with family-physician communication. Our prospective preintervention and postintervention study tested the hypothesis that introducing this informed consent process would improve family satisfaction with the ICU process of care.

Materials And Methods: We developed a consent form that included an introductory explanation of the main ICU interventions and a description of 8 common procedures in a surgical ICU.

Effects of routine monitoring of delirium in a surgical/trauma intensive care unit.

Background: Delirium is prevalent in surgical and trauma intensive care units (ICUs) and carries substantial morbidity. This study tested the hypothesis that daily administration of a diagnostic instrument for delirium in a surgical/trauma ICU decreases the time of institution of pharmacologic therapy and improves related outcomes.

Methods: Controlled trial of two concurrent groups.

The clinical significance of delirium in the intensive care unit.

Delirium is prevalent among intensive care unit patients. It prolongs length of stay, increases costs, and is independently associated with higher mortality rates. While its specific biological pathways are largely unknown, environmental and iatrogenic determinants have been repeatedly recognized.

Clinical and economic burden of postoperative pulmonary complications: patient safety summit on definition, risk-reducing interventions, and preventive strategies.

Objective: Postoperative pulmonary complications are a major contributor to the overall risk of surgery. We convened a patient safety summit to discuss ways to enhance physician awareness of postoperative pulmonary complications, advance postoperative pulmonary complications as a substantive public health concern demanding national attention, recommend strategies to reduce the deleterious impact of postoperative pulmonary complications on clinical outcomes and healthcare costs, and establish an algorithm that will help identify patients who are at increased risk for postoperative pulmonary complications.

Data Sources: We conducted PubMed searches for relevant literature on postoperative pulmonary complications in addition to using the summit participants' experience in the management of patients with postoperative pulmonary complications.

Modifying endotracheal tubes to prevent ventilator-associated pneumonia.

Purpose Of Review: The endotracheal tube (ETT) is the main avenue leading to airway contamination and subsequent ventilator-associated pneumonia (VAP) during mechanical ventilation. A number of modifications to the ETT are available, aimed at reducing the incidence of VAP. We review here available systems and devices, and clinical data regarding their efficacy.

Do Patients with Obstructive Sleep Apnea have an Increased Risk of Desaturation During Induction of Anesthesia for Weight Loss Surgery?

Background: Obstructive sleep apnea (OSA) is an independent risk factor to develop perioperative complications during weight loss surgery, but the mechanisms are unclear. It is possible, that patients with OSA have a higher incidence of desaturation during induction of anesthesia.

Methods: We enrolled 100 morbidly obese (body mass index: 53+/-10) adult patients undergoing open bariatric surgery in a prospective study.

Bradycardia leading to asystole during dexmedetomidine infusion in an 18 year-old double-lung transplant recipient.

The case of an 18 year-old double-lung transplant recipient recovering from acute respiratory distress syndrome who developed repeated episodes of bradycardia and asystole (maximum duration: 10 sec) during dexmedetomidine administration is presented. Increased baseline vagal tone, paroxysmal coughing spells, and opioid administration were likely contributors to the episodes. Discontinuation of the drug restored regular sinus rhythm.

Lateral-horizontal patient position and horizontal orientation of the endotracheal tube to prevent aspiration in adult surgical intensive care unit patients: a feasibility study.

Background: Recent data suggest that during mechanical ventilation the lateral-horizontal patient position (in which the endotracheal tube is horizontal) decreases the risk of ventilator-associated pneumonia, compared to the recommended semi-recumbent position (in which the endotracheal tube slopes downward into the trachea). We tested the feasibility of the lateral-horizontal patient position, measured the incidence of aspiration of gastric contents, and watched for any adverse effects related to the lateral-horizontal position.

Methods: Ten adult intensive care unit patients were ventilated for 64 hours in the standard semi-recumbent position, and ten for 12-24 hours in the lateral-horizontal position.

Comparison of conventional guaiac to four immunochemical methods for fecal occult blood testing: implications for clinical practice in hospital and outpatient settings.

Background: Fecal occult blood testing (FOBT) is one method to screen for colorectal cancer and to assess for gastrointestinal bleeding in hospitalized patients. Differences in the analytical sensitivity among various methods may have significant clinical repercussions.

Methods: We evaluated the analytical performance of 5 different FOBT methods (standard guaiac-based method and four immunochemical methods) using patient samples and spiked stool specimens.

Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit.

Objective: Diagnostic testing is frequently overused in the intensive care unit. We devised guidelines to optimize blood tests utilization, and designed this study to quantify their efficacy over time, their safety, and their possible benefits.

Design: Laboratory testing guidelines were created by consensus and implemented through repeated staff education.

Internally coated endotracheal tubes with silver sulfadiazine in polyurethane to prevent bacterial colonization: a clinical trial.

Objective: Coated medical devices have been shown to reduce catheter-related infections. We coated endotracheal tubes (ETT) with silver sulfadiazine (SSD), and tested them in a clinical study to assess the feasibility, safety, and efficacy of preventing bacterial colonization.

Design: A prospective, randomized clinical trial, phase I-II.

Tracheostomy tube malposition in patients admitted to a respiratory acute care unit following prolonged ventilation.

Background: Tracheostomy tube malposition is a barrier to weaning from mechanical ventilation. We determined the incidence of tracheostomy tube malposition, identified the associated risk factors, and examined the effect of malposition on clinical outcomes.

Methods: We performed a retrospective study on 403 consecutive patients with a tracheostomy who had been admitted to an acute care unit specializing in weaning from mechanical ventilation between July 1, 2002, and December 31, 2005.

Determinants of tracheostomy decannulation: an international survey.

Background: Although tracheostomy is probably the most common surgical procedure performed on critically ill patients, it is unknown when a tracheostomy tube can be safely removed.

Methods: We performed a cross-sectional survey of physicians and respiratory therapists with expertise in the management of tracheostomized patients at 118 medical centers to characterize contemporary opinions about tracheostomy decannulation practice and to define factors that influence these practices.

Results: We surveyed 309 clinicians, of whom 225 responded (73%).

The chest wall in acute lung injury/acute respiratory distress syndrome.

Purpose Of Review: There has recently been renewed interest in the chest wall during mechanical ventilation, related to lung-protective ventilation strategies, as well as in the role of abdominal pressure in many facets of critical illness. The purpose of this review is to address relevant issues related to the chest wall and mechanical ventilation, particularly in patients with acute lung injury/acute respiratory distress syndrome.

Recent Findings: In mechanically ventilated patients with acute lung injury, intra-abdominal pressure is an important determinant of chest wall compliance.

Computed tomography for early and safe discontinuation of cervical spine immobilization in obtunded multiply injured patients.

Background: Evaluation of the cervical spine (c-spine) in obtunded severely injured trauma patients is controversial, and spine immobilization is frequently prolonged. We examined the effect of two different c-spine evaluation protocols on c-spine immobilization and clinical outcomes.

Methods: We prospectively evaluated consecutive intubated and mechanically ventilated patients admitted to the surgical intensive care unit (ICU) of a Level I academic trauma center with a diagnosis of multiple blunt injuries who had normal findings on high-resolution helical computed tomogram of C1 to T1 with reconstructions (HCTrecon).

Outcome of patients undergoing prolonged mechanical ventilation after critical illness.

Objective: To examine the longitudinal outcome of a cohort of mechanically ventilated patients admitted to an acute care respiratory unit after critical illness.

Design, Setting, And Patients: Prospective, observational study of 210 consecutive patients admitted to a respiratory unit of an acute, tertiary care university hospital, who had an acute critical illness with respiratory failure. The study was powered to develop multivariate regression models to investigate the relationship between patient characteristics and a) liberation from mechanical ventilation and b) survival.