14 Jun 09
Posted in Critical Care, Infection at 8:00 by Laci
By N O’Grady, P Barie, J Bartlett, T Bleck, K Carroll, A Kalil, P Linden, D Maki, D Nierman, W Pasculle, H Masur
Crit Care Med 2008; 36:1330-1349
To update the practice parameters for the evaluation of adult patients who develop a new fever in the intensive care unit, for the purpose of guiding clinical practice.
Participants
A task force of 11 experts in the disciplines related to critical care medicine and infectious diseases was convened from the membership of the Society of Critical Care Medicine and the Infectious Diseases Society of America. Specialties represented included critical care medicine, surgery, internal medicine, infectious diseases, neurology, and laboratory medicine/microbiology.
Evidence
The task force members provided personal experience and determined the published literature (MEDLINE articles, textbooks, etc.) from which consensus was obtained. Published literature was reviewed and classified into one of four categories, according to study design and scientific value.
Consensus process
The task force met twice in person, several times by teleconference, and held multiple e-mail discussions during a 2-yr period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the strength of the recommendation. Draft documents were composed and debated by the task force until consensus was reached by nominal group process.
Conclusions
The panel concluded that, because fever can have many infectious and noninfectious etiologies, a new fever in a patient in the intensive care unit should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests. A cost-conscious approach to obtaining cultures and imaging studies should be undertaken if indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic decisions can be made.
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13 Jun 09
Posted in Quality measure at 10:55 by Laci
By R J Glavin
Anesthesiology 2009; 110:201–3
All truths are easy to understand once they are discovered; the point is to discover them. — Galileo Galilei
I invent nothing, I rediscover. — Auguste Rodin
THIS is the second editorial of four looking at excellence in anesthesiology. In the introductory editorial, Smith set the scene by encouraging us to look beyond the more conventional and obvious areas of the curriculum, such as knowledge of applied physiology or performance of regional anesthetic techniques, and to explore those areas that are less well defined but of equal importance for the complexity of our tasks as clinical anesthesiologists. The theme that is common to this series of editorials is that the different components of excellence are already present in the practice of anesthesiology and always have been, as Rodin observed in the quote above. Although present, these components are tacit and not explicit.
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12 Jun 09
Posted in Quality measure at 10:51 by Laci
By A Smith
Anesthesiology 2009; 110:4–5
WE owe it to our patients, our colleagues, and ourselves to strive for excellence in all that we do. Safe, highquality patient care, good working relationships, and our own professional pride and fulfillment are all at stake. Nevertheless, for all its importance, attempts to explore the many facets of excellence in anesthesiology have been made only recently. This editorial is the first in a series of four in which international anesthesiologists who have recently published on excellence and professionalism in our specialty will outline some of the methods available for the understanding and promotion of excellence.
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08 Jun 09
Posted in Sepsis at 1:47 by Laci
By C Torgersen, P Moser, G Luckner, V Mayr, S Jochberger, W Hasibeder, M Dunser
Anesth Analg 2009;108:1841–1847
Although detailed analyses of the postmortem findings of various critically ill patient groups have been published, no such study has been performed in patients with sepsis. In this retrospective cohort study, we reviewed macroscopic postmortem examinations of surgical intensive care unit (ICU) patients who died from sepsis or septic shock.
Methodes
Between 1997 and 2006, the ICU database and autopsy register were reviewed for patients who were admitted to the ICU because of sepsis/septic shock, or who developed sepsis/septic shock at a later stage during their ICU stay and subsequently died from of sepsis/septic shock. Clinical data and postmortem findings were documented in all patients.
Results
Postmortem results of 235 patients (84.8%) were available for statistical analysis. The main causes of death as reported in the patient history were refractory multiple organ dysfunction syndrome (51.5%) and uncontrollable cardiovascular failure (35.3%). Pathologies were detected in the lungs (89.8%), kidneys/urinary tract (60%), gastrointestinal tract (54%), cardiovascular system (53.6%), liver (47.7%), spleen (33.2%), central nervous system (18.7%), and pancreas (8.5%). In 180 patients (76.6%), the autopsy revealed a continuous septic focus. The most common continuous foci were pneumonia (41.3%), tracheobronchitis (28.9%), peritonitis (23.4%), uterine/ovarial necrosis (9.8% of female patients), intraabdominal abscesses (9.1%), and pyelonephritis (6%). A continuous septic focus was observed in 63 of the 71 patients (88.7%) who were admitted to the ICU because of sepsis/septic shock and treated for longer than 7 days
Conclusions
Relevant postmortem findings explaining death in surgical ICU patients who died because of sepsis/septic shock were a continuous septic focus in approximately 80% and cardiac pathologies in 50%. The most frequently affected organs were the lungs, abdomen, and urogenital tract. More diagnostic, therapeutic and scientific efforts should be launched to identify and control the infectious focus in patients with sepsis and septic shock.
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