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Safety of Contrast Agents in the Critically Ill

Safety of Contrast Agents in the Critically Ill

Ultrasound contrast agent safety in critically ill patients undergoing echocardiography has been questioned by the FDA. This controversy was the result of rare reports showing that deaths or life-threatening adverse reactions occurred in close proximity to the administration of ultrasound contrast agents. “Since these reports surfaced around 2007, many studies have been conducted to better define the safety profile of these agents,” says Michael L. Main, MD. An Observational Analysis In a large observational study published in JACC: Cardiovascular Imaging, Dr. Main and colleagues compared 48-hour all-cause mortalities and hospital stay mortalities among critically ill patients who underwent echocardiography either with or without an ultrasound contrast agent. Data were collected on more than a million participants through discharge information from a database that included information on primary and secondary diagnoses, procedure billing codes, and demographic and baseline patient information in addition to hospital characteristics. At discharge, more than 990,000 patients underwent echocardiography without a contrast agent, whereas 16,222 received a contrast agent for their exam. According to the results, ultrasound contrast agent use was associated with a 28% lower mortality rate at 48 hours among critically ill patients undergoing echocardiography when compared with no ultrasound contrast agent use. Recipients of ultrasound contrast agents also had significantly lower mortality rates over their entire hospital stay when compared with those who did not receive one (14.85% vs 15.66%). “Importantly, our findings were consistent across a wide variety of major comorbidities and important demographic subgroups, such as age and gender,” says Dr. Main. Overall, there were no groups with significantly greater odds for mortality after receiving a contrast agent. Impactful Findings Data...

Hospitalists & the Intensivist Shortage

The growing intensivist shortage is challenging hospitals’ ability to care for critically ill patients. Despite numerous recommendations that intensivists manage critically ill adults, the majority of American hospitals cannot meet this standard. As a consequence, hospitalists have become de facto intensivists in many hospitals, with 75% reporting that they practice in the ICU. While legitimate concerns have been raised whether hospitalists are uniformly qualified to practice in the ICU, the issue has become moot at many hospitals where intensivists are either in short supply or entirely absent. Efforts are needed to ensure that hospitalists manage critically ill patients safely, effectively, and seamlessly. In the Journal of Hospital Medicine and Critical Care Medicine, the Society of Hospital Medicine and the Society of Critical Care Medicine co-published a position paper on training the hospitalist workforce to address the intensivist shortage. In this paper, we discussed the potential value of hospitalists in the ICU and the importance of enhancing hospitalists’ skills to provide critical care services. Adding Value & Enhancing Skills of Hospitalists Hospital medicine and critical care medicine share similar structures, competencies, and values, positioning hospitalists as a logical solution to the intensivist shortage. Many of the competencies needed for practicing critical care medicine are encompassed in internal medicine training as well as in core competencies in hospital medicine. The ideology and mechanics of high-performing hospitalist and intensivist programs are similar, yet despite these commonalities, hospitalists remain largely untapped as a potential source of new intensivists. Exploring Alternative Critical Care Models With no solution to the intensivist shortage in sight, alternative critical care delivery models are needed. We proposed a 1-year...

Examining Length of Stay in 8-Hour Shifts

In previous research, studies have documented significant links between length of stay (LOS) over 24-hour periods and hospital occupancy, the number of ED admissions, and other factors. In the May 2012 Western Journal of Emergency Medicine, my colleagues and I published a study that looked at LOS in more discreet time periods than what earlier analyses have reported. We did this because ED crowding and volume can vary greatly during a given 24-hour period. We wanted to find out which factors were associated with LOS and whether this relationship was present during all or only specific 8-hour shifts. In our analysis, independent variables were measured during three 8-hour shifts. Shift 1 was from 7:00 am to 3:00 pm, shift 2 was from 3:00 pm to 11:00 pm, and shift 3 was from 11:00 pm to 7:00 am. For each shift, the numbers of ED nurses on duty, discharges, discharges on the previous shift, resuscitation cases, admissions and ICU admissions, and LOS on the previous shift, were measured. For each 24- hour period, the numbers of elective surgical admissions and hospital occupancy were measured, since these could not be measured in 8-hour time intervals. ED Length of Stay: Roles of Occupancy & Admissions On all three shifts, LOS increased by about 1 minute for each additional 1% increase in hospital occupancy. The mean hospital occupancy in our study was 94.9%; considering this high level of demand for inpatient beds, even a 1% increase in occupancy can lead to significant delays. The demand for inpatient beds often exceeds 100% capacity during the late morning and early afternoon hours on weekdays. To...

Procalcitonin & Antibiotic Decisions

The advent of antibiotic therapy has led to dramatic reductions in mortality and morbidity due to bacterial infections and sepsis. The overuse of antibiotics to treat infections, however, may expose patients to adverse events resulting from use of these agents and by increasing the risk of developing bacterial resistance. To fight the emergence of bacterial resistance to antimicrobial agents, more effective efforts are needed to reduce the inappropriate or unnecessarily prolonged use of antibiotics. A novel approach for determining the need and optimal duration of antibiotic therapy is to use biomarkers of bacterial infections (see also, Procalcitonin: A Biomarker for Early Sepsis Intervention). One such biomarker is procalcitonin (PCT), which has been shown to become up-regulated during bacterial infections. It also appears to mirror the extent and severity of infections. Measuring PCT levels may help physicians more rationally decide on prescriptions and duration of antibiotic therapy in patients with infections. Previous studies have suggested that using clinical algorithms based on PCT levels results in less antibiotic use without negatively affecting clinical outcomes. However, various trials using such algorithms have been conducted largely in European healthcare settings. New Data from Procalcitonin Algorithms In the August 8, 2011 Archives of Internal Medicine, my colleagues and I performed a systematic review of 14 randomized controlled trials that investigated PCT algorithms for antibiotic treatment decisions in adults with respiratory tract infections and sepsis from primary care, ED, and ICU settings. The aim was to summarize the evidence for using PCT measurements and to propose clinical algorithms for use in future trials in the United States. Our analysis revealed no significant differences in mortality...

Comparing Autopsy Approaches in the ICU

Virtual autopsy may be a useful alternative to medical autopsy for certain diagnoses, according to data from a small German study. The authors noted, however, that virtual autopsy missed more cardiovascular events and diagnoses while medical autopsy missed more traumatic fractures and pneumothoraces. Additional research is needed to confirm the results. Abstract: Annals of Internal Medicine, January 17,...
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