ICU Director

Objectives. To assess the utility of ultrasound-guided axillary artery catheterization compared with anatomical landmark technique catheterization in the intensive care unit. Design. Randomized controlled trial. Setting. University hospital surgical and neurosurgical intensive care unit. Patients. A total of 33 critically ill patients undergoing arterial line placement. Interventions. Axillary arterial line placement under ultrasound guidance or by using anatomical landmarks. Measurements and main results. Procedure duration, number of attempts (skin punctures), needle repositionings, and aborted procedures were compared. A total of 33 patients were randomly assigned to either the ultrasound group (n = 18) or the anatomical landmark group (n = 15). Aborted procedures were significantly greater in the landmark group (n = 4) than in the ultrasound group (n = 0); P = .019. Procedure duration (mean ± SD) in the ultrasound group was 7.01 ± 4.40 minutes compared with 9.29 ± 10.00 minutes in the landmark group; P = .360. A significant reduction in overall procedure duration for fellow operators (5.83 ± 3.64 minutes) versus resident operators (11.46 ± 9.41 minutes) was noted; P = .012. The number of attempts in the landmark group was 3.07 ± 2.96 compared with 2.44 ± 1.72 in the ultrasound group; P = .46. The number of needle repositionings was 4.06 ± 2.86 times per procedure in the ultrasound group, compared with 10.00 ± 13.45 in the landmark group; P = .077. Conclusion. Ultrasound-guided axillary arterial catheter placement increases the success rate of line placement with no significant decrease in the duration of the procedure and the number of needle punctures or repositionings.

Transesophageal echocardiography (TEE) has gained increasing popularity in the operating room and intensive care settings. The use of TEE can often times diagnose pathology that is missed by transthoracic echocardiography (TTE); in addition, it can be used as a guide to continuously monitor a patient’s hemodynamics, along with observing the direct cardiac effects of fluid and vasopressor therapy. We present a case of acute fulminant hepatic failure in the ICU, where TEE allowed a rapid diagnosis. We performed prolonged TEE monitoring (72 hours) of the patient to monitor the patient’s response to therapeutic interventions. We also discuss the diagnostic and therapeutic implications of prolonged TEE placement in the ICU. In addition, particular strategies to optimize the benefit and minimize the risk of this exciting, yet underutilized, technology are discussed.

ICU leaders need to be current with recent technological advances related to cardiac implantable electrical devices (CIEDs). This update will review the following 4 topics: (1) an update on contemporary technology for CIED companies headquartered in the United States, (2) unique features of one CIED company headquartered in Europe, (3) ICU considerations for patients with CIEDs for whom do not resuscitate orders are in place, and (4) evaluation of patients admitted to the ICU with incomplete medical information about a visible medical device that may be a CIED. This discussion will provide valuable information for the care of ICU patients with CIED.

A large acute care but nontrauma teaching hospital in Manhattan, New York performing 24 000 operations/year has evolved a Surgical Intensive Care Unit (SICU) Service with 3 attendings and 5 physician assistants over 9 years. The division follows nationally recognized, published best practices in shock, sepsis, ventilator management, nutrition, and antibiotic use and has maintained a total mortality of 1.9% (varying between 1.5% and 2.1%) for 9 years. Although PGY-1 and PGY-2 residents rotate through SICU, the division relies heavily on experienced, Fundamentals of Critical Care Support–trained physician assistants for organized consultation and ensuring adherence to best practices in daily patient care. For the past 4 years, the division has provided 24/7 in-house attending coverage in collaboration with the Division of Cardiac Surgery. In-house attending intensivist/cardiac surgeon coverage did not improve mortality. The division also provides approximately one third of the institution’s acute care surgery in rotation/collaboration with general surgeons. The practicalities of the division’s evolution and recommendations are discussed.

Background. Gainsharing is a pay-for-performance (P4P) program that provides incentives to attending physicians to reduce hospital costs while maintaining quality care. Hypothesis. Overall hospital costs decreased because of the gainsharing program during the past 4 years, while ICU costs increased over the same period because the incentives were given only to the discharging physician of record. Methods. Retrospective analysis was performed on the most frequent hospital and ICU admissions by All Patient Refined–Diagnosis Related Group (APR-DRG). A best practice norm was calculated by taking the mean hospital cost of the top 25 percentile. Savings opportunity (SO) was defined by subtracting the BPN from the actual cost. Gainsharing payments to the discharging physicians required meeting specific quality standards. Results. A total of 9034 patients were admitted to the ICU during the study period under this program. Among all APR-DRGs, total hospital costs decreased by $2.7 million (10%) for these specific admissions, mostly related to a shorter overall hospital stay. However, average ICU costs actually rose during the same period by $0.9 million (32%). The DRG with the greatest ICU SO was “tracheostomy with long-term mechanical ventilation” ($1.7 million). This group averaged $67 000 in ICU costs per patient but accounted for only 0.8% of the total number of admissions. There was also a savings opportunity for “septicemia” ($0.4 million, 2% of patients) and “small- and large-bowel surgery” ($0.4million, 1.5% of patients). Conclusions. The incentive to reduce costs was absent to physicians in the ICU, unlike the overall hospital, which experienced cost savings.