Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2015
ReviewBedside Ultrasound in the Intensive Care Unit: Where Is the Evidence?
Interest in bedside ultrasound in the intensive care unit and emergency department has exploded in recent years. This interest is driven in part by the utility of ultrasound for procedural guidance. In most cases, enthusiasm outstrips current evidence. ⋯ Other possibilities include ventilator titration and guidance of diuresis. While the literature is more complicated, there is some early evidence that lung ultrasound may improve the diagnosis of dyspnea, although these results have not been well validated. Centers should avoid premature loss of equipoise and participate in studies of explicit protocols that incorporate ultrasound.
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Semin Respir Crit Care Med · Dec 2015
ReviewIntensivist Staffing: Evolving Challenges and Solutions.
Increases in critical care utilization related to aging of our population, static supplies of critical care specialists, and reduced availability of physicians in training to staff intensive care units (ICUs) have led many institutions to reevaluate their ICU prescribing provider staffing plans. The epidemiology of critical care staffing needs, regulations, requirements, standards, and professional society staffing recommendations are reviewed and the components of a prescribing provider staffing plan are described along with their costs. Factors that impact staffing costs including the availability of intensivist extenders, electronic support, and telemedicine tools that impact the efficiency of care delivery are evaluated in the context of staffing plan evaluation. Financial modeling is used to compare the costs of common prescribing provider staffing plans for typical referral medical center ICUs, community hospital ICUs, and rural health centers that care for the critically ill.
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Intensive care unit (ICU) admission is common among patients approaching the end of their lives from acute as well as chronic life-limiting conditions. ICU providers are expected to have basic palliative care skills integrated into their routine practice. Palliative care skills can be applied to all ICU patients, regardless of prognosis, and may improve patient- and family-centered end of life (EOL) care in the ICU. ⋯ This review discusses integrative and consultative palliative care models and the role of triggers for palliative care consultation, particularly when they are tailored to the needs of individual ICUs. We then review the evidence for providing several palliative care domains in the ICU and some of the ethical considerations surrounding EOL care in the ICU. Finally, we highlight the importance of self-care and peer support groups to mitigate the risk of burnout for clinicians providing EOL care in the ICU.
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Semin Respir Crit Care Med · Dec 2015
ReviewCritical Care Beds and Resource Utilization: Current Trends and Controversies.
Recent studies have shown a dramatic increase in the number of intensive care unit (ICU) beds in recent decades. As technologies have become more complex, ICUs continue to grow in size and in specialization. The driving forces behind ICU bed expansion include not only the incorporation of advanced technologies but also other factors such as the increased utilization of ICU beds for patients who previously were not offered ICU care--those who may be terminally ill and those who are not critically ill. ⋯ ICUs are also now commonly used in the care of dying patients. In coming decades it is likely that changes will need to take place to forestall exorbitant costs and labor shortages. In addition to bringing in new forms of medical staff such as hospitalists and physician assistants, recent opinion papers have suggested that a de-escalation of ICU growth and a new tiered system of ICU care will be necessary in the United States.
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Semin Respir Crit Care Med · Dec 2015
ReviewControversies in the Management of Life-Threatening Pulmonary Embolism.
Patients with life-threatening pulmonary embolism (PE) offer clinicians a unique opportunity to intervene effectively on the patient's behalf. Hemodynamic status remains the most important short-term prognostic factor for patients with acute PE. Although the evidence is limited, the use of thrombolytic therapy is recommended for patients with acute symptomatic PE and associated hypotension or shock (i.e., high-risk PE) because these patients have a high short-term mortality risk (i.e., >15%) even when receiving anticoagulant treatment. ⋯ For patients with life-threatening PE at high risk of bleeding, clinicians might consider the use of low-dose thrombolytic therapy, catheter-directed thrombolysis, or surgical embolectomy, if they have access to the required expertise and resources. The evidence does not support the use of inferior vena cava filters in patients with life-threatening PE unless there is a contraindication to anticoagulation. Since various medical and surgical specialties offer different perspectives and expertise, a multidisciplinary approach to patients with intermediate- and high-risk PE might improve patient outcomes.