Systems of Care Delivery and Optimization in the Intensive Care Unit.

As the volume and complexity of patients requiring intensive care grows, so do the barriers and challenges to the delivery of that care. This article summarizes these challenges, outlines strategies used to overcome them, and presents new developments and concepts within the care of the ICU patient.

Reducing ICU Length of Stay: The Impact of a Multidisciplinary Perioperative Pathway in Vestibular Schwannoma.

Objective This study was aimed to evaluate the impact of a multidisciplinary perioperative pathway on length of stay (LOS) and postoperative outcomes after vestibular schwannoma surgery. Setting This study was conducted in a tertiary skull base center. Main Outcome Measures The impact of the pathway on intensive care unit (ICU) LOS was evaluated as the primary outcome measure of the study. Overall resource LOS, postoperative complications, and readmission rates were also evaluated as secondary outcome measures. Methods Present study is a retrospective review. Results A universally adopted perioperative pathway was developed to include standardization of preoperative education and expectations, intraoperative anesthetic delivery, postoperative nursing education, postoperative rehabilitation, and utilization of stepdown and surgical floor units after ICU stay. Outcomes were measured for 95 consecutive adult patients who underwent surgical resection for vestibular schwannoma (40 cases before implementation of the perioperative pathway and 55 cases after implementation). There were no significant differences in the two groups with regard to tumor size, operative time, or medical comorbidities. The mean ICU LOS decreased from 2.1 in the preimplementation group to 1.6 days in the postimplementation group ( p = 0.02). There were no significant differences in overall resource LOS postoperative complications or readmission rates between groups. Conclusion Multidisciplinary, perioperative neurotologic pathways can be effective in lowering ICU LOS in patients undergoing vestibular schwannoma surgery without compromising quality of care. Further research is needed to continue to sustain and continuously improve these and other measures, while continuing to provide high-quality care to this patient population.

Propylthiouracil-Associated Leukocytoclastic Necrotizing Cutaneous Vasculitis: A Case Report and Review of the Literature.

The purpose of this case report and review of the literature is to provide an exploration of the clinical symptoms, diagnosis, prevention, and management of propylthiouracil (PTU)-associated vasculitis in the intensive care setting. A PubMed search of the available literature was conducted using the MeSH search terms "propylthiouracil" and "vasculitis." The literature search returned 121 articles. Twenty-five were excluded because they were not in English. Fifty-nine case reports or case studies describing PTU-associated vasculitis were included. Data extracted from each case study included patient age, sex, autoimmune markers, laboratory tests, length of time on PTU, treatment for vasculitis, and patient outcomes. The authors reviewed 128 cases of PTU-associated vasculitis. The majority were women (8.8:1 F:M ratio), and the most common presenting symptoms were rash (51.6%), fever (46.9%), and arthralgia (43.8%). In addition to discontinuing PTU, the most common treatment was steroids (71.9%). Eight patients (6.3%) progressed to end-stage renal disease; two (1.6%) required intubation for respiratory failure; and five (3.9%) died of various organ systems failure related to vasculitis development. A high index of suspicion for vasculitis should be maintained, especially when presented with skin manifestations in the presence of PTU therapy. Screening with myeloperoxidase-antinuclear cytoplasmic antibodies is most sensitive. Positive screening should prompt a thorough clinical investigation. In cases of severe skin manifestations, the focus should be on aggressive wound care. Our case report is unique, not only in the size and extent of cutaneous involvement, but also as the first description of mortality secondary to cutaneous manifestations.

Electrophysiologic deterioration in surgery for thoracic disc herniation: impact of mean arterial pressures on surgical outcome.

OBJECTIVE: Severe thoracic disc herniation leads to increased pressure in adjacent neural structures, which in turn can require an increase in mean arterial pressure (MAP) to maintain adequate spinal cord perfusion. We report a case series of three patients with severe thoracic disc herniation that experienced deteriorations in motor-evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) following induction of general anesthesia, but prior to decompression of the neural elements. METHODS: In-depth chart reviews were completed for each patient from their initial presentation to long-term post-operative course. Careful attention was taken with regards to MAP at induction of each operative case. RESULTS: The origin of the decreased signals in all patients was thought to relate to inadequate cord perfusion pressures. Two of the patients recovered pre-operative neurologic function while the third was left with mild post-operative paraparesis. Mean arterial pressures at time of deterioration were noted to be 58, 80, and 60 mmHg. These measurements represented MAPs approximately 65, 92, and 60 % those of baseline values, respectively. CONCLUSION: Based on these experiences, the authors' institution has adopted new guidelines in the setting of thoracic disc herniations that includes pre-operative optimization of volume status, placement of an awake arterial line prior to induction of anesthesia, use of MEP and SSEP electrophysiologic monitoring, careful selection of anesthetic, and aggressive maintenance of MAPs >110 % of preoperative values at all times prior to decompression of the spinal cord.