Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Society of Critical Care Medicine.

OBJECTIVE: The development of practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit (ICU) setting for the purpose of guiding clinical practice. PARTICIPANTS: A task force of more than 40 experts in disciplines related to the use of analgesic and sedative agents in the ICU was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM). EVIDENCE: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, pharmacopeias, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four predetermined categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times as a whole, and numerous times in smaller groups by teleconference, over a 1-yr period to identify the pertinent literature and arrive at consensus recommendations for the whole task force to discuss. Consideration was given to the relationship between the weight of scientific information and the experts' viewpoints. Over the next year, draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft was then reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. DATA SYNTHESIS: To facilitate rapid communication of the six recommendations contained within the complete and unabridged practice parameter document, an executive summary was prepared for publication by the ACCM Board of Regents, and this executive summary was approved by the task force steering committee and the SCCM Executive Council. CONCLUSIONS: A consensus of experts provided six recommendations with supporting data for intravenous analgesia and sedation in the ICU setting: a) morphine sulfate is the preferred analgesic agent for critically ill patients; b) fentanyl is the preferred analgesic agent for critically ill patients with hemodynamic instability, for patients manifesting symptoms of histamine release with morphine, or morphine allergy; c) hydromorphone can serve as an acceptable alternative to morphine; d) midazolam or propofol are the preferred agents only for the short-term (< 24 hrs) treatment of anxiety in the critically ill adult; e) lorazepam is the preferred agent for the prolonged treatment of anxiety in the critically ill adult; f) haloperidol is the preferred agent for the treatment of delirium in the critically ill adult. This executive summary selectively presents supporting information and is not intended as a substitute for the complete document.

Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: an executive summary. Society of Critical Care Medicine.

OBJECTIVE: The development of practice parameters for achieving sustained neuromuscular blockade in the adult critically ill patient for the purpose of guiding clinical practice. PARTICIPANTS: A task force of more than 40 experts in disciplines related to the use of neuromuscular blocking agents in the intensive care unit was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM). EVIDENCE: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, pharmacopeias, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four predetermined categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times as a whole, and numerous times in smaller groups by teleconference, over a 1-yr period to identify the pertinent literature and arrive at consensus recommendations for the whole task force to discuss. Consideration was given to the relationship between the weight of scientific information and the experts' viewpoints. Over the next year, draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft was then reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. DATA SYNTHESIS: To facilitate rapid communication of the three recommendations contained within the complete and unabridged practice parameter document, an executive summary was prepared for publication by the ACCM Board of Regents, and this executive summary was approved by the task force steering committee and the SCCM Executive Council. CONCLUSIONS: A consensus of experts provided three recommendations with supporting data for achieving sustained neuromuscular blockade in critically ill patients: a) pancuronium is the preferred neuromuscular blocking agent for most critically ill patients; b) vecuronium is the preferred neuromuscular blocking agent for those patients with cardiac disease or hemodynamic instability in whom tachycardia may be deleterious; c) patients receiving neuromuscular blocking agents should be appropriately assessed for the degree of blockade that is being sustained. This executive summary selectively presents supporting information and is not intended as a substitute for the complete document.

Influence of the acquired immunodeficiency syndrome on resource availability in critical care medicine in the coming decade.

Information presented regards the consumption of resources in the management of critically ill patients with the acquired immunodeficiency syndrome (AIDS). Predictions are made about future increases in critical care services for patients with this condition. While increased need will primarily be related to an increased number of patients with AIDS, an expanded need for critical care services is also likely to result from changes in the populations at risk and in the presentation of the syndrome. In particular, the relationship between the AIDS epidemic and tuberculosis is described. The balance between AIDS research costs and the care of patients with the syndrome, as well as the availability of resources, is likely to become less favorable as healthcare reform unfolds. A number of suggestions for coping with this imbalance include efforts to achieve better selection of patients for ICU admission and to employ aggressive therapies and alternative treatments that do not require ICU admission. Creative administrative planning, including the use of case management, therapist-driven protocols, intensified utilization review, regionalization, and expansion of home health services, is discussed. It is necessary for clinicians to demonstrate that therapies result in survival and other substantial benefits. The need to keep legislators informed of new achievements in critical care and a new focus on preventive care are emphasized.

Mechanical ventilatory support in circulatory shock.

Mechanical support of ventilation is associated with a number of hemodynamic consequences that result from direct and indirect hydrostatic phenomena, humoral effects, and changes in distribution of peripheral blood flow, particularly in patients with circulatory shock. Each of these is discussed in detail, and recommendations are made for harnessing these effects in order to improve circulation.

History, general overview, and protection of health care workers.

This article provides a background so that the intensivist can appreciate the social and cultural context in which the AIDS epidemic developed. The upheaval that AIDS has caused in the gay community is described along with some of the economic effects AIDS has had on that population and on the practice of medicine, both locally and nationally. Also reviewed are changes that have taken place in the handling of patients and biologic secretions in order to protect health care workers from contamination from the causative virus. Finally, this article discusses changes in the AIDS patient population and clinical manifestations of the disease.

Acute respiratory failure due to Pneumocystis carinii pneumonia.

Pneumonia caused by Pneumocystis carinii is the most frequent indication for admission of AIDS patients to intensive care units. In this article, an approach to the diagnosis and management of this condition will be presented along with prognostic information. Differential diagnosis will be discussed, and characteristic responses to current standard and alternative chemotherapeutic agents and modes of ventilatory support will be reviewed.

Descriptive analysis of critical care units in the United States.

OBJECTIVE: To gather data about available technology, staffing, administrative policies, and bed capacities of ICUs in the United States. DESIGN AND SETTING: On January 15, 1991, survey instruments were mailed to the administrators of 4,233 hospitals to gather information from the medical director of the institutions' respective ICUs for the purpose of developing a database on ICUs in the United States. The sampling frame for this study was based on all American Hospital Association (AHA) hospitals that stated they have ICUs. MEASUREMENTS: Census questionnaires solicited information on types of hospitals, types of ICUs, number of ICU beds open and closed, technology available to the unit, organizational structure and management of the ICU, as well as the staffing and certification of unit personnel. MAIN RESULTS: Data were obtained on 32,850 ICU beds with 25,871 patients from 2,876 separate ICUs in 1,706 hospitals in the United States. Census responses came from units in all sizes of hospitals within all ten census regions in the country, all states, and all types of hospital sponsorship (federal, state, and local government, private nonprofit and private for profit). The census response rate was 40% of the AHA hospitals that stated that they have ICUs, with specific ICU data on 38.7% of the nation's ICUs. The number of ICUs per hospital increases with overall hospital size. The smallest hospitals (less than 100 beds) usually had only one ICU. As hospital size increased, the single, all inclusive medical/surgical/coronary care units diminished, and in hospitals with greater than 300 beds, specialization of units became prevalent. In absolute terms, hospitals had the following number of ICUs: 1.04 +/- 0.20 (less than or equal to 100 beds); 1.30 +/- 0.65 (101 to 300 beds); 2.37 +/- 1.58 (301 to 500 beds); and 3.34 +/- 2.21 (greater than 500 beds). ICU beds averaged, nationally, 8.09% of hospital-licensed beds with a median of 6.98%. Generally, medical units, pediatric units, coronary care units (CCUs), and medical/surgical/CCUs reported an average of 10 beds per unit. Neonatal units averaged 21 beds, and surgical units averaged 12 beds. The average ICU size, nationally, was 11.7 +/- 7.8 beds per unit. Available technology within hospitals and individual units was increased as hospital size increased; surgical units tended to have more available technology than other unit types. A wide range of organizational arrangements within hospitals determines where the ICU appears in an organizational chart and to whom unit management is accountable. Thirty-six percent of the units were located organizationally within the hospital's department of medicine, while 23% were considered "free standing," having no departmental affiliation. Although units must have a medical director, the perception as to whether this director supervises the day-to-day operation was different in larger vs. smaller hospitals. In hospitals with less than or equal to 100 beds, 72% of the units were perceived to be supervised by the medical director, whereas in larger hospitals (greater than 500 beds), 81% of units were supervised. Study results indicated that medical directors in pediatric, neonatal, and burn units most often were perceived to supervise the unit. Presently, 63% of all ICUs responding are directed by an internist. The next largest group to direct ICUs were surgeons, followed by pediatricians. Pediatrician involvement tended to be exclusive in pediatric and neonatal units. Surgeons directed most surgical and neurologic units and were involved in 21% of mixed medical/surgical units. Internists predominated in medical units and in CCUs, as well as in combined medical/surgical/CCUs. Direction by anesthesiologists, although relatively infrequent, predominated in the surgical unit. Critical care medicine certification of the medical director and attending staff of the ICU increased as hospital size increased, although only 44% of all units stated that thei

Availability of critical care personnel, facilities, and services in the United States.

This survey of 1474 special care units in the United States found that smaller hospitals tended to have only one ICU. The number of ICUs increased with overall hospital size; when a hospital had two ICUs, the second unit was usually for coronary care. Internists directed most of the ICUs, followed in decreasing order by surgeons, family practitioners, anesthesiologists, and pediatricians. More than 40% of ICUs were directed by cardiologists, reflecting the frequency of coronary care units. About eight times as many pulmonary medicine physicians directed ICUs as intensivists trained in critical care medicine. An increasing number of ICU directors received salaries for their services as hospital size increased, and the size of this salary also tended to increase with unit size. Average nurse/patient ratios tended to be better than 1:2.3 for all shifts. Few ICUs used private-duty nurses, although a substantial number required per-diem nurses. The level of nurse education increased with the size of the unit. The number of house officers varied widely according to hospital size, as did the numbers of subspecialty fellows and nonphysician professional and paraprofessional personnel. The availability of services in hospitals also varied according to hospital size, particularly for intra-aortic balloon counterpulsation, CT scanning, and intracranial pressure monitoring. Urban setting more significantly affected size and available services than did geographic region.(ABSTRACT TRUNCATED AT 250 WORDS)

Physician manpower in critical care medicine.

Former trainees in Critical Care Medicine (CCM) were polled regarding the reasons which have dissuaded intensivists from continuing practice in the field. Among the reasons cited, the most common were poor reimbursement for services rendered and the constant rivalry among practitioners in various fields for responsibilities in caring for the critically ill. A greater portion of anesthesiologists have discontinued practice in CCM than internists. Among those trained in CCM fellowship programs who are still practicing CCM, internists are most numerous.

Cardiac performance in response to PEEP in patients with cardiac dysfunction.

The effect of PEEP on cardiac performance was evaluated in 21 patients with left ventricular (LV) dysfunction. Twenty-three data sets were divided into three groups according to pulmonary arterial wedge pressure (PAWP). In three of four group A data sets (PAWP = 12 mm Hg), cardiac output (CO) decreased when PEEP was added. In four of six group B data sets (PAWP = 14-18 mm Hg) and in 12 of 13 group C data sets (PAWP less than or equal to 19 mm Hg), CO increased with addition of PEEP. In group C, the mean increase in CO was 500 ml/min, and the mean level of best PEEP was 3.9 cm H2O. When PAWP exceeded 18 mm Hg, PEEP was safe and in many instances augmented CO.

Effectiveness of intensive nutritional regimes in patients who fail to wean from mechanical ventilation.

Over a 2-year period, 14 viable ventilator-dependent patients were transferred from the Medical Intensive Care Unit (MICU) to a general ward floor for nutritional support after failing to wean from mechanical ventilation (MV) while in the MICU. These patients were retrospectively grouped based on their ultimate ability to wean from MV: group 1 (N = 6) did not wean from MV and ultimately died in the hospital; group 2 (N = 8) weaned from MV and were eventually discharged. Before transfer from the MICU, the two groups did not differ with regard to serum albumin or transferrin levels, or in total lymphocyte count. After the period of aggressive nutritional support, group 2 patients showed an increase in serum albumin and transferrin whereas patients in group 1 showed a decrease. The differences between these groups were significant (p less than 0.05). The lymphocyte count did not change significantly. Ventilator-dependent patients who respond to nutritional support with an increase in protein synthesis are more likely to wean from mechanical ventilation than those who do not.

The value of routine daily chest x-rays in intubated patients in the medical intensive care unit.

Two hundred routine chest x-rays were evaluated to determine their value in the management of critically ill patients in a Medical ICU (MICU). Seventy-four x-rays (37%) were of suboptimal value or were delivered to the MICU too late for inclusion on morning rounds. Of the remaining 126 films, 54 (43%) showed worsening of a known, or development of a new, cardiopulmonary abnormality, or an unexpected misplacement of an invasive device. On the basis of these findings, routine daily chest radiographs were judged to be valuable in identifying abnormalities in critically ill patients. However, the system for providing this service was only 63% efficient, and improvement must be sought in this regard.

Cerebral function monitoring in deeply comatose patients.

The cerebral function monitor (CFM) was used in 26 subjects, deeply comatose for a variety of reasons, in order to determine its value as a prognosticator for survival in this group of patients. Results suggest that it may be useful in predicting outcome in patients who do not regain neurologic competence within 2 h after cardiac arrest and resuscitation. In this group, initial CFM values of 10 muv or above correlated well with survival, and values of 3 muv or below correlated with death. The instrument was not a useful tool in predicting outcome in patients with dynamic primary neurological disorders, although a reduction in the CFM tracing did precede deterioration in clinical neurological function in some. The value of the CFM could not be determined by patients with drug overdosage because of the small size of this group.