Critical Care Transport of the Temporary Portable Ventricular Support Device.

OBJECTIVE: Cardiogenic shock is a critical emergency for which ventricular support devices (VSDs), such as the Impella (AbioMed Inc, Danvers, MA), are placed. Many referring facilities cannot provide cardiac intensive care. This requires a regional approach to the care of patients with VSD. Critical care transport to the regional center is needed and requires specialty trained personnel. As the need for specialty trained personnel increases, appropriate utilization of the personnel needs to be considered. This study illustrates the effective transport and successful management of Impella patients in the transport environment by a downsized specialty trained critical care team. METHODS: A retrospective chart review explored critical care transports of patients with Impella devices over a 73-month period. Our goal was to show that with training, protocols, and guidelines a downsized critical care team can effectively transport these high-risk, low-frequency patients. RESULTS: Forty-seven VSD transports occurred within 13,823 transports during the study period. Twenty-seven included an Impella device only. Thirteen were completed by a downsized team. One hundred percent of the transport resulted in the patient having perfusing rhythms and blood pressures at the receiving facility. CONCLUSION: VSDs can be successfully transported between hospitals with small specialty trained critical care transport teams using air or ground assets.

A Case Study of Long-Range Rotary Wing Critical Care Transport in the Battlefield Environment.

Military medical evacuation continues to grow both in distance and transport times. With the need for long-range transport of greater than 2 hours, crews are having to manage critical care patients for longer trips. This case study evaluates one specific event in which long-range transport of a sick noncombat patient required an enroute critical care team. Medical electronics and other equipment require special attention. Oxygen bottles and batteries for medical devices become the limiting factor in transport from point to point. Having to juggle multiple data streams requires prioritization and reassessment of interventions. Using the mnemonic "bottles, bags, batteries, battlefield environment" keeps the transport paramedic and enroute care nurse on track to effectively deliver the patient to the next level of care. Consideration should be given to such mnemonics for long critical care transports.

Point-of-Care Laboratory Data Collection During Critical Care Transport.

OBJECTIVE: Critical care transport involves a high level of intensive clinical care in a resource-limited environment. These patients require multiple assessments guiding specialty treatments, including blood product administration, intravenous electrolyte replacement, ventilator management, and extracorporeal membrane oxygenation. This study aims to measure the usage of point-of-care (POC) laboratory data during critical care transport. METHODS: Data were collected via electronic medical record review over 1 year of use in a hospital-based critical care rotor wing, fixed wing, and ground critical care transport team in the Southeastern United States. RESULTS: One hundred twenty POC tests were performed during 1,075 critical care transports over the 1-year period (8.9%). Patient transportations involved 35 extracorporeal membrane oxygenation, 21 medical, 17 cardiac, 13 neonatal, 11 respiratory failure, 8 gastrointestinal bleeding, 6 neurologic, 5 pediatrics, 3 trauma, and 1 organ donor. Seventy-eight POC laboratory tests (65%) required intervention, including ventilator changes (39.7%), electrolyte replacement (35.8%), blood products (7.6%), and other (12.8%). The remaining 42 (35%) POC laboratory tests confirmed no intervention was necessary (n = 35) and that ongoing treatments were effective (n = 7). CONCLUSION: POC laboratory testing performed during critical care transport guides providers in performing essential emergent interventions in a timelier manner that may benefit critically ill patients.

A multidisciplinary initiative to standardize intensive care to acute care transitions.

QUALITY ISSUE: Transfers from intensive care units to acute care units represent a complex care transition for hospitalized patients. Within our institution, variation in transfer practices resulted in unpredictable processes in which patient safety concerns were raised. INITIAL ASSESSMENT: Key stakeholders were engaged across the institution. Patient safety ('incident') reports and a staff survey identified safety concerns. CHOICE OF A SOLUTION: Using lean methodology, current transfer processes were mapped for the four adult intensive care units and waste was identified. During a summit of key stakeholders an ideal transfer process was conceived and a structured handoff tool (checklist) was developed. A daily management system (DMS) was implemented to monitor adherence. EVALUATION: The primary process outcome was adherence to the standardized workflow. Audits at 4, 8, and 12 months after implementation indicated that the checklist was used for 100% of transfers. Secondary outcomes included the percentage of transfers completed within a pre-specified time window of 120 minutes, provider notification of patient arrival on the acute care unit, and staff survey responses assessing adequacy of transfer communication. LESSONS LEARNED: Prior work has shown that structuring handoffs can improve patient safety, but the novelty of this project was addressing the transfer process in its entirety, across silos of care. Factors leading to the success of this project were the involvement of key stakeholders across the entire institution early in the project development phase, employment of lean methodology, and implementation of tools to guide workflow adherence and track causes of deviation from the workflow.

Genetic variation in soluble epoxide hydrolase: association with outcome after aneurysmal subarachnoid hemorrhage.

OBJECT: Patients with aneurysmal subarachnoid hemorrhage (SAH) are at high risk for delayed cerebral ischemia (DCI) and stroke. Epoxyeicosatrienoic acids (EETs) play an important role in cerebral blood flow regulation and neuroprotection after brain injury. Polymorphisms in the gene for the enzyme soluble epoxide hydrolase (sEH), which inactivates EETs, are associated with ischemic stroke risk and neuronal survival after ischemia. This prospective observational study of patients with SAH compares vital and neurologic outcomes based on functional polymorphisms of sEH. METHODS: Allelic discrimination based on quantitative real-time polymerase chain reaction was used to differentiate wild-type sEH from K55R heterozygotes (predictive of increased sEH activity and reduced EETs) and R287Q heterozygotes (predictive of decreased sEH activity and increased EETs). The primary outcome was new stroke after SAH. Secondary outcomes were death, Glasgow Outcome Scale score, and neurological deterioration attributable to DCI. RESULTS: Multivariable logistic regression models adjusted for age at admission and Glasgow Coma Scale scores revealed an increase in the odds of new stroke (OR 5.48 [95% CI 1.51-19.91]) and death (OR 7.52 [95% CI 1.27-44.46]) in the K55R group, but no change in the odds of new stroke (OR 0.56 [95% CI 0.16-1.96]) or death (OR 3.09 [95% CI 0.51-18.52]) in patients with R287Q genotype, compared with wild-type sEH. The R287Q genotype was associated with reduced odds of having a Glasgow Outcome Scale score of ≤ 3 (OR 0.23 [95% CI 0.06-0.82]). There were no significant differences in the odds of neurological deterioration due to DCI. CONCLUSIONS: Genetic polymorphisms of sEH are associated with neurological and vital outcomes after aneurysmal SAH.

Chlamydia trachomatis infection may increase the risk of preeclampsia.

BACKGROUND: Although the etiology of preeclampsia is not well understood, it has been suggested that excessive systemic inflammation may lead to oxidative stress, promoting the endothelial dysfunction characteristic of preeclampsia. Few prospective studies have examined the role of infection, an immune system stimulator, as a risk factor for preeclampsia. METHODS: We conducted a longitudinal study of the relationships between Chlamydia trachomatis (CT), Chlamydophila pneumoniae (CP), cytomegalovirus (CMV), herpes simplex virus (HSV) and preeclampsia among 509 preeclamptic cases and 336 normotensive controls nested within the Danish National Birth Cohort study. Antibodies were analyzed at a first prenatal visit (mean 17.0weeks) and at a late second/third trimester study visit. Prenatal infections were identified as IgG/IgM seroconversion or a fourfold rise in IgG antibody titers. Multiple regression models were adjusted for maternal age, BMI, smoking status, and time between blood draws. RESULTS: CT infection was associated with preeclampsia (ORadj 1.6, 95% CI 0.7, 3.6), severe preeclampsia (ORadj 1.8, 95% CI 0.6, 5.3), and preeclampsia resulting in preterm birth (ORadj 1.7, 95% CI 0.6-4.9) or birth of a small for gestational age infant (ORadj 2.1, 95% CI 0.6, 7.5), although CT infection was uncommon (n=33, 4.0%) and associations were not statistically significant. CP, CMV, and HSV infection were not associated with preeclampsia. CONCLUSIONS: Women with serological evidence of prenatal CT infection were more likely to develop preeclampsia, although infection was infrequent and confidence intervals were wide. Studies in populations at higher risk for STIs are needed to corroborate this association.