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The goal of this meta-analysis was to determine the utility of real-time two-dimensional (2D) ultrasound guidance for femoral artery catheterization.Despite the shift toward establishing vascular access via the radial artery rather than the femoral artery, femoral artery cannulation is still frequent in cardiac catheterization. Since vascular complications related to femoral artery cannulation can be quite devastating, preventing these complications is vital.A comprehensive literature search of Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials was performed. Additionally, five years of conference abstracts from critical care, interventional radiology, vascular surgery, and cardiology were reviewed. Two independent reviewers identified prospective, randomized controlled trials comparing ultrasound guidance with traditional palpation techniques of femoral artery catheterization (with or without fluoroscopy). Data were extracted on study design, study size, operator and patient characteristics, complication rates, first-pass success, procedure time, and number of attempts.Four trials with a total of 1422 subjects were included in the review, with 703 subjects in the palpation group and 719 subjects in the ultrasound-guided group. Compared with traditional methods, ultrasound guidance for femoral artery catheterization was associated with 49% reduction in overall complications, including hematoma and accidental venipuncture (relative risk, 0.51; 95% confidence interval, 0.28-0.91). It was also associated with 42% improvement in the likelihood of first-attempt success (relative risk, 1.42; 95% confidence interval, 1.01-2.00).The use of real-time 2D ultrasound guidance for femoral artery catheterization decreases life-threatening vascular complications and improves first-pass success rate.

BACKGROUND: Accurate interpretation of chest radiographs (CXR) is essential as clinical decisions depend on readings. OBJECTIVE: We sought to evaluate CXR interpretation ability at different levels of training and to determine factors associated with successful interpretation. DESIGN: Ten CXR were selected from the teaching file of the internal medicine (IM) department. Participants were asked to record the most important diagnosis, their certainty in that diagnosis, interest in a pulmonary career and adequacy of CXR training. Two investigators independently scored each CXR on a scale of 0 to 2. PARTICIPANTS: Participants (n=145) from a single teaching hospital were third year medical students (MS) (n=25), IM interns (n=44), IM residents (n=45), fellows from the divisions of cardiology and pulmonary/critical care (n=16), and radiology residents (n=15). RESULTS: The median overall score was 11 of 20. An increased level of training was associated with overall score (MS 8, intern 10, IM resident 13, fellow 15, radiology resident 18, P

We report a case of vascular assess challenge on a patient with severe kyphoscoliosis and joint contractures. Multiple internal jugular (IJ) central venous catheters (CVC) and a peripherally inserted central catheter (PICC) catheterization were attempted via ultrasound guidance and all resulted in malposition. The PICC attempt fortuitously pushed a malpositioned IJ into the correct position. Computed tomography (CT) demonstrated a narrow thoracic inlet with no definite venous stenoses. Therefore, severe chest wall deformity, a narrow thoracic inlet and inadequate positioning of the patient secondary to his contractures all contributed to the malposition of the PICC and CVCs.

Purpose: Despite studies regarding outcomes of day versus night medical care, consequences of nighttime extubations are unknown. It may be favorable to extubate patients off-hours, as soon as weaning parameters are met, since this could decrease complications and shorten length of stay (LOS). Conversely, nighttime extubation could be deleterious, as staffing varies during this time. We hypothesized that patients have similar reintubation rates, irrespective of extubation time. Methods: A retrospective cohort study performed at 2 hospitals within a tertiary academic medical center included all adult intensive care unit (ICU) patients extubated between July 01, 2009 and May 31, 2011. Those extubated due to withdrawal of support were excluded. The nighttime group included patients extubated between 7:00 pm and 6:59 am and the daytime group included patients extubated between 7:00 am and 6:59 pm. Results: Of 2240 extubated patients, 1555 were extubated during the day and 685 were extubated at night. Of these, 119 (7.7%) and 26 (3.8%), respectively, were reintubated in 24 hours with likelihood of reintubation significantly lower for nighttime than daytime after multivariable adjustment (odds ratio [OR] = 0.5, 95% confidence interval [CI] 0.3-0.9, P = .01), with a similar trend for reintubation within 72 hours (OR = 0.7, 95% CI = 0.5-1.0, P = .07). There was a trend toward decreased mortality for patients extubated at night (OR = 0.6, 95% CI = 0.3-1.0, P = .06). There was also a significantly lower LOS for patients extubated at night ( P = .002). In a confirmatory frequency-matched analysis, there was no significant difference in reintubation proportion or mortality, but LOS was significantly less in those extubated at night. Conclusions: Intensive care unit extubations at night did not have higher likelihood of reintubation, LOS, or mortality compared to those during the day. Since patients should be extubated as soon as they meet parameters in order to potentially decrease complications of mechanical ventilation, these data provide no support for delaying extubation until daytime.

Recent evidence suggests that retrieval practice, or learning by testing, may lead to more effective knowledge retention than standard educational techniques.The purpose of this pilot project was to document successful teaching of evidence-based guidelines in critical care by augmenting interactive problem-based teaching sessions with online pre- and post-testing.We used a free, internet-based document collaboration system (Google Docs™) 1 to develop and share pre-tests and pre-session teaching files with the fellows. At the teaching sessions the pre-tests were reviewed interactively, and additional case-based questions were presented. One week after the sessions, the fellows were sent a post-test and a post-session survey. Results of the pre- and post-tests as well as the post-session surveys were tabulated by the document collaboration system.The mean score was 54.6% (SD = 21.4%) on the pre-tests and 87.0% (SD = 15.8%) on the post-tests (p0.01). On a scale of 1-10, the median ratings given by the fellows were 9.5 (IQR = 9-10) for utility of the teaching sessions, 9 for utility of the test questions (IQR = 9-10), and 10 (IQR = 9-10) for utility of the teaching files.Google Docs™ can be successfully used to integrate retrieval practice into the teaching of evidence-based guidelines in critical care.

Introduction. Fast and accurate diagnosis of alveolar-interstitial syndrome is of major importance in the critically ill. We evaluated the utility of lung ultrasound (US) in detecting and localizing alveolar-interstitial syndrome in respective pulmonary lobes as compared to computed tomography scans (CT).Methods. One hundred and seven critically ill patients participated in the study. The presence of diffuse comet-tail artifacts was considered a sign of alveolar-interstitial syndrome. We designated lobar reflections along intercostal spaces and surface lines by means of sonoanatomy in an effort to accurately localize lung pathology. Each sonographic finding was thereafter grouped into the respective lobe.Results. From 107 patients, 77 were finally included in the analysis (42 males with mean age=61±17years, APACHE II score=17.6±6.4, and lung injury score=1.0±0.7). US exhibited high sensitivity and specificity values (ranging from over 80% for the lower lung fields up to over 90% for the upper lung fields) and considerable consistency in the diagnosis and localization of alveolar-interstitial syndrome.Conclusions. US is a reliable, bedside method for accurate detection and localization of alveolar-interstitial syndrome in the critically ill.

Heart failure with a normal or nearly normal left ventricular (LV) ejection fraction (HFNEF) may represent more than 50% of heart failure cases. Although HFNEF is being increasingly recognized, there is a relative lack of information regarding its incidence and prognostic implications in intensive care unit (ICU) patients. In the ICU, many factors related to patient’s history, or applied therapies, may induce or aggravate LV diastolic dysfunction. This may impact on patients’ morbidity and mortality. This paper discusses methods for assessing LV diastolic function and the feasibility of their implementation for diagnosing HFNEF in the ICU.

The purpose of this study was to evaluate the effectiveness of a simulation-based workshop with ultrasonography instruction in reducing mechanical complications associated with central venous catheter (CVC) insertion.A single-center prospective cohort study was conducted in the medical ICU and respiratory step-down unit of an urban teaching hospital. Fifty-six medical house staff members were trained prior to their rotations over a 6-month period. The data on mechanical complication rates after the implementation of the workshop were compared with previous experience when no structured educational program existed.There were 334 procedures in the preeducation period compared to 402 procedures in the posteducation period. The overall complication rate, including placement failure, in the preeducation and posteducation period was 32.9% and 22.9%, respectively (P.01). Placement failure rate decreased from 22.8% to 16.2% (P = .02), and arterial punctures decreased from 4.2% to 1.5% (P = .03). Ultrasonography usage increased from 3.0% to 61.4% (P.01). Multivariate analysis demonstrated that interns were more likely to cause overall mechanical complications compared with fellows and attending physicians in the preeducation period (P = .02); however, this trend was not observed in the posteducation period. Catheter site and ultrasonography usage significantly affected the overall complication rate in both periods, and ultrasound-guided femoral CVC was the safest procedure in the posteducation period.Implementation of a prerotational workshop significantly improved the safety of CVC insertion, especially for CVCs placed by inexperienced operators. We suggest that simulation-based training with ultrasonography instruction should be conducted if house staff members are responsible for CVC placement.

Non-invasive measurement of intracranial pressure can be invaluable in the management of critically ill patients. We performed a comprehensive review of the literature to evaluate the different methods of measuring intracranial pressure. Several methods have been employed to estimate intracranial pressure, including computed tomography, magnetic resonance imaging, transcranial Doppler sonography, near-infrared spectroscopy, and visual-evoked potentials. In addition, multiple techniques of measuring the optic nerve and the optic nerve sheath diameter have been studied. Ultrasound measurements of the optic nerve sheath diameter and Doppler flow are especially promising and may be useful in selected settings.

Objective To determine the impact of simulation-based maternal cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff. Study Design Maternal-Fetal Medicine staff (n = 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life suppport pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring. Results Postintervention scores reflected statistically significant improvement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P = .042) and cesarean delivery (240 vs 159 seconds, P = .017). Conclusion Prompt cardiopulmonary resuscitation initiation and pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for Maternal-Fetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event.

Objective Ultrasonography is an effective tool for making quick diagnoses and guiding therapeutic procedures. National organizations have advocated increasing the use of critical care ultrasonography. The purpose of this study was to investigate the prevalence of teaching of critical care ultrasonography in fellowship programs. In addition, we hoped to identify barriers to establishment of ultrasound training programs. Design All pulmonary/critical care and critical care medicine (CCM) program directors in the United States were invited to participate in an online survey. We asked respondents for demographic information about their programs and perceived barriers to training, as well as current training opportunities for their fellows in five aspects of critical care ultrasonography. A five-point Likert scale was used for survey answers. Setting Web-based survey. Subjects Pulmonary/critical care and CCM program directors in the United States. Interventions Web-based survey. Measurements and main results Ninety (66%) of 136 program directors responded. Ultrasonography training was offered by fellowship programs in the following areas: vascular access (98%), lung and pleural (74%), cardiac (55%), vascular diagnostic (33%), and abdominal (37%). Ninety-two percent of respondents agreed or strongly agreed that ultrasound training is useful, and 80% were interested in getting their fellows trained. Forty-one percent indicated that they lacked sufficient faculty trained in ultrasound use. Eighty-four percent agreed or strongly agreed that fellow turnover was an impediment to training. Forty-eight percent believed that cardiac echocardiography required a long training time. Conclusions Although ultrasound training in vascular access was nearly universal, training in other aspects of ultrasound was less prevalent. We identified several barriers, including fellow turnover, insufficient faculty training, and perceived length of time required for echocardiography training.

On January 15, 2009, US Airways Flight 1549 hit geese shortly after takeoff from LaGuardia Airport in New York City. Both engines lost power, and the crew quickly decided that the best action was an emergency landing in the Hudson River. Due to the crew's excellent performance, all 155 people aboard the flight survived. Intensivists can learn valuable lessons from the processes and outcome of this incident, including the importance of simulation training and checklists. By learning from the aviation industry, the intensivist can apply principles of crew resource management to reduce errors and improve patient safety. Additionally, by studying the impact of the mandated process-engineering applications within commercial aviation, intensivists and health-care systems can learn certain principles that, if adequately and thoughtfully applied, may seriously improve the art and science of health-care delivery at the bedside.

An accurate perception of time is critical for responders to cardiac arrests and other medical emergencies. Interventions such as medications or defibrillation are meant to be given at particular times. External chest compressions and bag-valve mask ventilations should be done at a particular rate. Accurate timing of the length of pulselessness may have implications for post-emergency management. Additionally, reported timing of pulselessness may alter clinicians' perception of the patient's chances for neurological recovery. Prior research indicates that stressful situations may impair subjects' time perception. It is hypothesized that this is true for responders to medical emergencies. Although there are many competing factors, responders to medical emergencies most likely feel that time passes more slowly than it actually does. This could have important implications for patient management both during and after medical emergencies.

Scenario-based training (SBT) with a computerized patient simulator (CPS) is effective in teaching physicians to manage high-risk, low-frequency events that are typical of critical care medicine. This study compares the initial airway management skills of a group of senior internal medicine residents trained using SBT with CPS during their first year of postgraduate training (PGY) with a group of senior internal medicine residents trained using the traditional experiential method.This was a prospective, controlled trial that compared two groups of PGY3 internal medicine residents at an urban teaching hospital. One group (n = 32) received training in initial airway management skills using SBT with CPS in their PGY1 (ie, the simulation-trained [ST] group). The second group (n = 30) received traditional residency training (ie, the traditionally trained [TT] group). Each group was then tested during PGY3 in initial airway management skills using a standardized respiratory arrest scenario.The ST group performed significantly better than the TT group in 8 of the 11 steps of the respiratory arrest scenario. Notable differences were found in the ability to attach a bag-valve mask (BVM) to high-flow oxygen (ST group, 69%; TT group, 17%; p0.001), correct insertion of oral airway (ST group, 88%; TT group, 20%; p0.001), and achieving an effective BVM seal (ST group, 97%; TT group, 20%; p0.001).Traditional training consisting of 2 years of clinical experience was not sufficient to achieve proficiency in initial airway management skills, mostly due to inadequate equipment usage. This suggests that SBT with CPS is more effective in training medical residents than the traditional experiential method.

We examined risk factors associated with failure of arterial catheterization in the medical intensive care unit of a large urban teaching hospital. We analyzed 92 consecutive arterial catheterizations by internal medicine house staff and critical care fellows. Of the 92 attempts, 26.1% were done on femoral arteries, and 73.9% were done on radial arteries. Failure, which occurred in 28% of attempts, was more common in female patients ( P < .001). The failure rate was 50.0% for attempts on femoral arteries and 20.6% on radial arteries. Systolic blood pressure was significantly lower in patients where the attempt failed ( P = .024). In univariate analyses, hemoglobin values were lower ( P = .028) and number of percutaneous punctures were higher ( P = .019) in patients where catheterization failed. After multivariate analysis, only gender and systolic blood pressure remained statistically significant. The strongest predictor of failure was female gender. A possible explanation not explored here could be smaller arterial size in female patients.

Sir: Arterial catheterization is a common intensive care unit (ICU) procedure. We have previously found that women are more likely to fail catheter attempts [1]. Few prior studies have investigated gender differences in arterial size. Men have larger left main and left anterior descending (LAD) coronary arteries, independently of body surface area (BSA) [2]. Herity et al. [3] found increased LAD size in hearts transplanted from female donors to male recipients. Krejza et al. found men have larger carotid arteries [4]. Babuccu et al. [5] studied the diameters of radial, thoracodorsal, and dorsalis pedis arteries in pediatric patients and found that age, weight, and male gender are associated with larger size. The radial and femoral arteries are commonly used for arterial catheter placement. We studied arterial size in these locations to determine whether men have larger arteries. The study was conducted over a 4-month period beginning 11 May 2005 in the medical ICU of an urban teaching hospital. The study was approved by the Beth Israel Medical Center Institutional Review Board and was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki. The requirement for written informed consent was waived. An Acuson Cypress 7.5 MHz ultrasound probe with 0.1-mm resolution was used (Siemens, Malvern, Pa., USA). Arterial diameter was measured in the transverse orientation of arterial diameter in systole. Measurements were taken during three different cardiac cycles and averaged. Radial arteries were measured 2 cm proximal to the distal wrist crease. Femoral arteries were measured one-third of the way from the pubic symphysis to the superior iliac crest. Based on clinical observations prior to the study we estimated that men’s femoral arteries would be 1 mm larger than women’s, and that their radial arteries would be 0.5 mm larger. Setting α at 5% and β at 20%, we calculated that 30 patients would be required to detect this difference in femoral arteries, and 36 patients would be required for radial arteries. Associations between demographic characteristics and arterial size were assessed by

We analyzed 385 consecutive central venous catheter (CVC) attempts over a 6-month period. All critically ill patients 18 years of age or older requiring a CVC were included. The rate of mechanical complications not including failure to place was 14%. Complications included failure to place the CVC (n = 86), arterial puncture (n = 18), improper position (n = 14), pneumothorax (n = 5 in 258 subclavian and internal jugular attempts), hematoma (n = 3), hemothorax (n = 1), and asystolic cardiac arrest of unknown etiology (n = 1). Male patients had a significantly higher complication rate than female patients (37% vs 27%, P = .04). The subclavian approach had a higher complication rate than the internal jugular or the femoral approach (39% vs 33% vs. 24%, P = .02). The complication rate increased with the number of percutaneous punctures, with a rate of 54% when more than 2 punctures were required.

To evaluate the effect of a standardized worksheet on physicians' and nurses' perceptions of their understanding of goals of care and on patients' length of stay in an intensive care unit.A worksheet was completed daily during multidisciplinary rounds and was posted at each bedside in the medical intensive care unit at Beth Israel Medical Center in New York. Information recorded included tests or procedures, medications, sedation, analgesia, catheters, consultations, nutrition, mobilization, family discussions, consents, and disposition. Attending physicians, residents, and nurses completed a questionnaire before implementation of the worksheet and 3 times afterwards. Responses were scored on a 5-point scale (1 = understand nothing, 5 = completely understand). Continuous variables were analyzed by using a t test; categorical variables, by using a chi(2) test.Before the worksheet was implemented, scores for understanding goals were 3.9 for nurses and 4.6 for physicians. Scores increased to 4.8 for nurses (P = .001) and 4.9 for physicians (P = .03) 6 weeks later, an improvement that remained at 9 months. Both groups showed significant improvement in communication scores that lasted for 9 months. Most responders wanted to continue using the worksheet. During the study, the mean stay in the unit was 4.3 days, down from 6.4 days for the analogous 9-month period in the preceding year (P= .02).Nurses' and physicians' perceptions of their understanding of the goals of care and of communication between them were improved and stays in the unit were shortened when the worksheet was used.

Purpose Accurate interpretation of the electrocardiogram is critical, yet there are no evidence-based guidelines for assessing competency. Our study evaluated the ability of internal medicine residents and emergency medicine residents to interpret a variety of electrocardiograms. Methods The 120 participants included 87 internal medicine residents and 33 emergency medicine residents at two hospitals. Participants reported their sex, training level, adequacy of training, career interest in cardiology, and estimated electrocardiogram proficiency. They then took a test containing 12 electrocardiograms and recorded their diagnosis and certainty. Two cardiologists independently established the correct diagnoses. Two blinded, independent graders scored each electrocardiogram (0 = incorrect, 1=partially correct, 2=correct). Results The median proficiency was 6 out of 10, total electrocardiogram score was 15 of 24, and certainty was 33 of 48. There was no significant difference in overall competency between emergency medicine and internal medicine residents (14.0 vs 15.0, P = 0.239). Internal medicine residents interested in a cardiology career scored higher than those not interested in a cardiology career (17.3 vs. 14.1, P = 0.003). When analyzing the most critical diagnoses, we found that the mean score for ventricular tachycardia was 1.6 of 2.0, for myocardial infarction was 1.3 of 2.0, and for complete heart block was 0.8 of 2.0. Over half of the participants felt their electrocardiogram training was inadequate. Conclusion Despite improvement in interpretation with clinical experience, overall performance was low. Research is needed to find optimal methods to improve electrocardiogram competency.