Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative.

OBJECTIVES: Patients and caregivers can experience a range of physical, psychologic, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism. DESIGN: We sought to identify technical, safety, and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation. SUBJECTS AND SETTING: Seventeen Thrive sites from the United States, United Kingdom, and Australia were represented by a range of healthcare professionals. MEASUREMENTS AND MAIN RESULTS: Via an iterative process of in-person and email/conference calls, members of the Collaborative defined the key areas on which peer support models could be defined and compared, collected detailed self-reports from all sites, reviewed the information, and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Within the Thrive Collaborative, six general models of peer support were identified: community based, psychologist-led outpatient, models-based within ICU follow-up clinics, online, groups based within ICU, and peer mentor models. The most common barriers to implementation were recruitment to groups, personnel input and training, sustainability and funding, risk management, and measuring success. CONCLUSIONS: A number of different models of peer support are currently being developed to help patients and families recover and grow in the postcritical care setting.

Perioperative implications of the patient with autonomic dysfunction.

PURPOSE OF REVIEW: The autonomic nervous system functions to control heart rate, blood pressure, respiratory rate, gastrointestinal motility, hormone release, and body temperature on a second-to-second basis. Here we summarize some of the latest literature on autonomic dysfunction, focusing primarily on the perioperative implications. RECENT FINDINGS: The variety of autonomic dysfunction now extends to a large number of clinical conditions in which the cause or effect of the autonomic component is blurred. Methods for detecting dysautonomia can be as simple as performing a history and physical examination that includes orthostatic vital signs measured in both recumbent and vertical positions; however, specialized laboratories are required for definitive diagnosis. Heart rate variability monitoring is becoming more commonplace in the assessment and understanding of autonomic instability. Degenerative diseases of the autonomic nervous system include Parkinson's disease and multiple system atrophy, with the most serious manifestations being postural hypotension and paradoxical supine hypertension. Other conditions occur in which the autonomic dysfunction is only part of a larger disease process, such as diabetic autonomic neuropathy, traumatic brain injury, and spinal cord injury. SUMMARY: Patients with dysautonomia often have unpredictable and paradoxical physiological responses to various perioperative stimuli. Knowledge of the underlying pathophysiology of their condition is required in order to reduce symptom exacerbation and limit morbidity and mortality during the perioperative period.

Technical communication: An initial evaluation of a novel anesthetic scavenging interface.

Waste anesthetic gas scavenging technology has not changed appreciably in the past 30 years. Open reservoir systems entrain high volumes of room air and dilute waste gases before emission into the atmosphere. This process requires a large vacuum pump, which is both costly to install and, although efficient, operates continuously and at near-full capacity. In an era of increasing energy costs and environmental awareness, carbon footprint reduction is a priority and a more efficient system of safely scavenging waste anesthetic gases is desirable. We tested a low-flow scavenger interface to evaluate the potential for cost and energy savings. The use of this interface in a suite of 4 operating rooms reduced scavenging flow from a constant 37 L/min to a value equal to the fresh gas flow (usually 2 L/min) for each anesthesia machine. Using the ventilator increased this flow by approximately 6 L/min because of the exhaust of ventilator drive gas into the scavenging circuit. Daytime workload of the central vacuum pump decreased from 92% to 12% (expressed as duty cycle). The new system produces energy savings and may increase vacuum pump lifespan.

Acute dermal capillary rupture associated with noninvasive blood pressure monitoring.

We report a case of Rumpel-Leede phenomenon, or acute dermis capillary rupture, secondary to noninvasive blood pressure monitoring in a patient with type 2 diabetes mellitus. The most likely cause was increased venous pressure during cycling of the blood pressure cuff during a hypertensive state. Anesthesiologists need to be aware that acute dermal capillary rupture, although rare, can occur in patients with thrombocytopenia and/or long-standing diabetes.