Journal of Intensive Care Medicine

Pulmonary aspiration of gastric contents can cause a spectrum of sequelae that spans from relatively minor to rapidly lethal disease. To emphasize the extent of this spectrum and to encompass both noninfectious complications and infection, we use the term “aspiration-induced pulmonary injury” rather than “aspiration pneumonia.” In this article we review the relevant literature, focusing on more recent insights into the pathogenesis of lung injury, the natural history of aspiration, risk factors, the relationship between aspiration and infection, and recommendations for management. The relevance to human disease of studies using intra-airway acid instillation in animals is questioned. We discuss the difficulties in predicting the clinical course after aspiration. We identify risk factors for aspiration-induced pulmonary injury that are commonly encountered in the intensive care unit, and discuss in detail factors of special interest to the intensivist, including the impact of tracheal intubation; the effects of enteric intubation, particularly the comparison between pre- and postpyloric routes of enteric feeding administration; and the relative risks associated with particular feeding protocols. We conclude with recommendations regarding treatment and prevention strategies.

The findings of the SUPPORT study, the largest, most comprehensive and costly study ever undertaken on decision making for critically ill patients, revealed a wide ranging gap between patient preferences and physician behavior with regard to treatment decisions for seriously ill patients. The ethical issues raised by that disparity are intensified as we enter into a market-driven managed care delivery system. This essay explores recent ethical and legal developments on several emerging issues: the decision making process; DNR orders; brain death; withdrawal of treatment; physician assisted suicide; and the constraints of managed care.

The logistical, technical, and medical considerations involved in the aeromedical transport of the mechanically ventilated patient arc considerable, and not well described in the literature. We review our experience with the prolonged (14.5 hr) air transport of a mechanically ventilated patient on a commercial airline. Practical and clinical issues are highlighted including equipment requirements and composition of the team, influences of altitude on equipment, and effects of altitude on the patient. A clear understanding of flight physiology and its impact on the patient and equipment are mandatory if one is to provide optimal care to these patients. The present report integrates our own experiences with data available from the literature, and may thus assist in both planning and undertaking any future such ventures for critically ill patients.

Evidence-based medicine is an approach to practicing medicine in which the clinician is aware of the evidence in support of her practice and the strength of that evidence. It requires daily application of systematic methods for finding, appraising, and incorporating the best available evidence in the care of individual patients. The evidence-based medicine approach compliments and enhances clinician expertise. It helps clinicians put the burgeoning medical literature into perspective. This article outlines the rationale of evidence-based medicine and lists resources for learning this approach and for finding repositories of evidence applicable to the critically ill pediatric population. We address the unique challenges posed by the smaller populations typically evaluated in pediatric critical care and practical constraints of incorporating evidence-based medicine into the fast-paced practice of critical care.

Minimizing the high oxygen consumption and energy expenditure of the critically ill is an important therapeutic goal. This study was done to determine if neuromuscular blockade decreases oxygen consumption or energy expenditure more than sedation alone in the mechanically ventilated child. Twelve burned children, with an average age of 5.1- 1.6 yrs, average weight of 22.8 − 6.5 kg, and average burn size of 28.3 − 5.8% of the body surface, scheduled for a planned surgical procedure under general anesthesia were enrolled in this prospective self-controlled study. In conjunction with planned operative procedures and using an intravenous anesthetic technique, the children underwent expired gas collection before and after neuromuscular blockade was induced. Expired gas was collected and analyzed for the fractional concentration of oxygen and carbon dioxide. Oxygen consumption (VO₂), carbon dioxide production (VCO₂), energy expenditure (EE), and respiratory quotient (RQ) were calculated. We found no significant difference in EE, VO₂, VCO₂, or RQ between the well-sedated and mechanically ventilated and the well-sedated, mechanically ventilated and paralyzed states. We therefore concluded that neuromuscular blockade does not decrease energy expenditure in the otherwise well-sedated burned child.

Etomidate is a rapidly acting, intravenous anesthetic agent. Because of its limited effects on cardiovascular function, it has generally been used for the induction of anesthesia in adult patients with compromised cardiorespiratory function. There is limited information concerning its use in children. The author presents three cases and reviews the possible applications of etomidate in the pediatric population.