ICU Director

Case

The patient is a 20-year-old male who was a pedestrian struck by a moving motor vehicle at a speed of 40 to 50 miles per hour. He was brought in to the emergency department (ED) with a Glasgow Coma Scale score of 5 (V1, E2, M2). He was intubated in the ED. His vital signs were as follows: heart rate of 126 beats per minute, blood pressure of 130/78, spontaneous breathing but on the ventilator, and neurological examination consisting of flexor posturing in the upper extremities and slight withdrawal in the lower extremities. His pupils were 4 mm and reactive, there was no blink to threat, and he did not open his eyes to voice or deep stimuli. His initial CT head scan demonstrated a small left subdural hematoma, blood in the left lateral ventricle, a left orbital fracture, and a right occipital fracture. Subsequent imaging also showed pneumocephalus in the anterior horns of the lateral ventricles and small blood in the posterior pons.

This hospital has a designated specialized neuro-ICU, with 24/7 coverage, residents, and NPs. However, there were no beds available at this time. The patient was admitted to a medical-surgical ICU.

Pheochromocytomas can secrete catecholamines, hormones, and cytokines, and the patterns of secretion strongly influence the complexity of the clinical presentation. We now report a patient who presented with abdominal pain, fever, leukocytosis, and tachycardia. In addition, he had lactic acidosis without shock. Our review of the literature indicates that this patient had systemic inflammatory response syndrome most likely secondary to high levels of IL-6 and that he had type B lactic acidosis secondary to high circulating levels of epinephrine. The combined presentation is unique and resolved with successful surgery. Pheochromocytoma should be included in the differential diagnosis of SIRS and of lactic acidosis.

Congestive heart failure is a major public health challenge and a leading cause of hospitalization in the United States. Despite major recent advances in the treatment of this condition, morbidity and mortality rates remain unacceptably high, and readmission rates can approach 50% at 6 months. Rehospitalization rates associated with this condition pose a significant economic burden on the health care budget. The main purpose of this article is to address how utilization of multidisciplinary heart failure units for the treatment of acute heart failure can lead to optimization of health care delivery for this condition, improved clinical outcomes, decreased rehospitalization rates, and reduced health care costs. We will explore the societal impact of heart failure and economic burden of this condition, with special focus on the impact of acutely hospitalized heart failure patients. Shortcomings and windfalls in the delivery of health care for this condition will be addressed. The multiple components of care essential to successful treatment of heart failure will be discussed. The article will then discuss how development of a formal multidisciplinary inpatient heart failure disease management program will consolidate and centralize all these various components and provide for optimal delivery of health care for this condition.

Implementation of tight glycemic control in hospitalized ICU patients presents a significant health care challenge. Many patients are involved, and implementation of tight glycemic control uses many hours of critical care nursing time. The current literature provides little practical guidance, older literature offers examples of tight glycemic control protocols, and the more recent NICE-SUGAR study involved the use of a computer-driven algorithm. This article provides the critical care physician direction for the organization of blood glucose control in the ICU. Discussion of an effective, safe, and user-friendly algorithm for intravenous insulin administration is presented, and safety considerations are discussed.