Reevaluation of the utilization of arterial blood gas analysis in the Intensive Care Unit: effects on patient safety and patient outcome.

PURPOSE: Arterial blood gas (ABG) analysis is a useful tool to evaluate hypercapnia in the context of conditions and diseases affecting the lungs. Oftentimes, indications for ABG analysis are broad and nonspecific and lead to frequent testing without test results influencing patient management. MATERIALS AND METHODS: Electronic charts of 300 intensive care unit (ICU) patients at a single institution were reviewed retrospectively. Reassessment of indications for ABGs led to a decrease of the number of ABGs in the ICU between March and November 2012. Data relating to ventilator days, length of stay, number of reintubations, mortality, complications after arterial puncture, demographics, and medications in 159 ICU patients between December 2011 and February 2012 (group 1) were compared with 141 ICU patients between December 2012 and February 2013 (group 2). Subgroup analysis in ventilated patients was performed. RESULTS: A decrease of number of ABGs per patient (6.12 ± 5.9, group 1 vs 2.03 ± 1.66, group 2 in ventilated patients; P = .007) was found along with a decrease in the number of ventilator days per patient (P = .004) and a shorter length of stay for ventilated patients in group 2 compared with group 1 (P = .04). CONCLUSION: A significant decrease of ABGs obtained in the ICU does not negatively impact patient outcome and safety. A decrease in the number of ABGs per patient allows cost-efficient patient care with a lower risk for complications.

Anaphylaxis.

BACKGROUND: Anaphylaxis is the quintessential critical illness in emergency medicine. Symptoms are rapid in onset and death can occur within minutes. Approximately 1500 patients die annually in the United States from this deadly disorder. It is imperative, therefore, that emergency care providers be able to diagnose and appropriately treat patients with anaphylaxis. Any delays in recognition or initiation of therapy can result in unnecessary increases in patient morbidity and mortality. DISCUSSION: Recent literature, including updated international anaphylaxis guidelines, has improved our understanding and management of this critical illness. Anaphylaxis is a multisystem disorder that can manifest signs and symptoms related to the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. Epinephrine remains the drug of choice and should initially be administered intramuscularly, into the anterolateral thigh, as soon as the diagnosis is suspected. For patients unresponsive to repeated intramuscular injections, a continuous infusion of epinephrine should be started. Antihistamines and corticosteroids are second-line medications and should never be given in lieu of, or prior to, epinephrine. Aggressive fluid resuscitation should also be used to treat the intravascular volume depletion characteristic of anaphylaxis. Patient observation and disposition should be individualized, as there is no well-defined period of observation after resolution of signs and symptoms. CONCLUSIONS: For patients with anaphylaxis, rapid and appropriate administration of epinephrine is critical for survival. Additional therapy, such as supplemental oxygen, intravenous fluids, antihistamines, and corticosteroids should not delay the administration of epinephrine.

Back pain emergencies.

Most adults in the United States will experience an episode of back pain at some point during their lifetime. Most will present to their primary care physician for evaluation and treatment. Many patients have non-life-threatening etiologies and recover within 4 to 6 weeks. A small percentage, however, have back pain due to a potentially life-threatening emergency. AD,rupturing AAA, SEM, cauda equina syndrome, vertebral osteomyelitis,and SEA are just some of the medical emergencies that can present with back pain. Clinical suspicion for these diagnoses begins with a thorough history and physical examination. It is imperative that the office-based physician search for and accurately identify any red flag within the history or physical examination. Appropriate laboratory studies and diagnostic imaging are obtained based on the suspected etiology.