ICU Director

Objective: To determine if the institution of a ventilator-associated pneumonia (VAP) prevention protocol was associated with VAP decrease in mechanically ventilated patients at a long-term acute care (LTAC) hospital over time. Introduction: VAP is the most common serious nosocomial infectious disease in mechanically ventilated patients. It has a high mortality and morbidity and significantly increases the cost of care. Design: A prospective preintervention and postintervention observational study comparing the number of episodes of VAP per 1000 patient ventilator-days in the 16 months preceding and 120 months (10 years) after the introduction of a VAP prevention protocol. Setting: A 73-bed, university-affiliated LTAC hospital. Methods: The implementation of a VAP prevention protocol included the following: (1) head of bed raised at 30°; (2) twice-weekly whole-body chlorhexidine-based bath with mupirocin 2% ointment applied to nares; (3) adequate hand washing; (4) adequate nutrition; (5) early tracheotomy by Day 7 if patients had endotracheal tubes; (6) monitor staff compliance; (7) infection control–run campaign involving posters, handouts, small group education events, positive reinforcement of good infection control practices, and focus on hand washing and universal precautions. Results: The initial VAP rate of 6.1 fell to 1.98/1000 ventilator-days within 5 months (P < .001), and this was maintained. Relative risk was 0.32 (P = .001) (68% relative risk reduction). Conclusion: The institution of a VAP prevention protocol showed a significant reduction in VAP episodes after the first 5 months of implementation. This rate was sustained for 10 years.

Objective: To describe a rare case of thyroid storm with atypical presentation resulting from conversion of Hashimoto’s thyroiditis with hypothyroidism to Graves’ disease. Methods: The authors present a case report, including the detailed clinical, laboratory, and radiographic data. They also review other significant reports available in the literature. Results: A 61-year-old woman with a history of long-standing hypothyroidism and more recently of erratic behavior, hallucination, and polysubstance abuse presented to the hospital with altered mental status. In the following 3 days, she developed lethargy, tachycardia, respiratory failure, and severe lactic acidosis. She was afebrile. Clinical features, thyroid function tests, thyroid antibody panel, and thyroid ultrasound were indicative of Graves’ disease developed on a preexisting Hashimoto’s thyroiditis. Clinical conditions rapidly improved after initiation of treatment for thyroid storm. Conclusion: This is the first reported case of thyroid storm resulting from conversion of hypothyroidism due to Hashimoto’s thyroiditis to Graves’ hyperthyroidism. Moreover, the case suggested that an atypical presentation of thyroid storm without fever could be a negative prognostic sign because of the possible association with severe lactic acidosis.

Vignette: An 88-year-old woman visiting from out of town, and out of network, presents to the emergency department with chest pain and rapidly progressing. Delays in the emergency department due to bed capacity lead the patient to be placed under the care of a hospitalist and emergency department physician while waiting for a floor bed. She develops increasing hemodynamic instability and is “upgraded” to an ICU bed with a presumptive diagnosis of septic shock. The ICU team is called.

Undifferentiated hypotension remains a central diagnostic and therapeutic challenge in emergency and critical care medicine. Increasingly, bedside ultrasound conducted by intensivists and emergency medicine providers is assuming a central role in diagnosis and resuscitation of hypotension. This review discusses sample algorithms for the bedside ultrasonographic assessment of undifferentiated shock and outlines an evidence-based framework for the intensivist seeking to incorporate bedside ultrasound into daily clinical practice. The literature regarding specific applications including cardiac, thoracic, pulmonary, and vascular assessment is briefly reviewed, as is the evidence pertaining to effective implementation, training, credentialing, and ongoing quality assurance.

An ICU is a geographically distinct area of a hospital where critically ill and injured patients undergo continuous monitoring and support of failing organ systems. Although a number of ICU organizational models exist, the optimal model requires the frequent presence of intensivists at the patient’s bedside supported by a multidisciplinary team of health care professionals. This article explores the history of critical care medicine and the evolution of different staffing models.