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Historically, telemedicine has focused on the application of traditional physician-to-patient (and physician-to-physician) interactions enhanced by two-way video and audio capability. This "one-on-one" interaction via a telemedicine link can dramatically extend a physician's or other caregiver's geographic range and availability. However, this same telemedicine model is most often implemented "on-demand" for a specified time-limited encounter. The remote Intensive Care Unit (ICU) model to be described similarly expands the geographic range of ICU physicians, but also allows a single specialist to simultaneously monitor multiple patients on a continuous basis by leveraging computerized "intelligent" algorithms and an electronic medical record interface. This new application of telemedicine wedded to computer technology facilitates maximum leveraging of specialists' cognitive skills but also mandates significant process changes in how ICU services are provided. In short, the remote ICU represents a "re-engineering" of how ICU care is delivered and establishes a new paradigm for the field of telemedicine, expanding the reach, scope and availability of intensivist specialty expertise.The re-engineering occurs through a number of ways. First, the telemedicine connection is continuously available in a pro-active fashion that can be provided 24 hours a day, 7 days a week (24/7). Secondly, the system utilizes computerized clinical intelligence algorithms with direct electronic links to physiologic, laboratory and lab/pharmacy data as well as patient diagnoses to focus attention on potential adverse outcomes or trends in individual patients and notify caregivers before trends manifest as adverse outcomes. Third, the traditional physician, nurse, and patient relationship is substantially augmented when there is an ICU physician immediately available to address issues in patient care, particularly at night when physicians are less likely to be present at the bedside. The current preliminary data suggest that this system can be quite effective in improving ICU quality of care, thus leading to reductions in the cost of ICU care, ICU patient mortality, ICU patient outliers, and ICU length of stay (LOS). Given the extensive data showing improved ICU outcomes with daily ICU physician participation in care of critically ill patients, and the national shortage of ICU physicians, nurses, and ancillary staff; the electronic ICU system is gaining popularity as an alternative paradigm for the expansion of an ICU team's expertise in the care of the severely ill. Interestingly, internal Quality Improvement (QI) data from several healthcare systems have shown that improved outcomes occur even when remote ICU telemedicine is applied to a pre-existing 24/7 in-house intensivist care model. The reasons for this remain speculative at this point, but pro-active and hourly remote "virtual rounds" on the most critically-ill patients, and use of computerized algorithms in triaging ICU physicians' attention may contribute to the success of this system. Also, we will show how the system supports key elements of error reduction theory even in well-staffed critical care units. Multiple challenges remain before remote ICU systems become more broadly accepted and applied. These include cost of implementation of the system, resistance to the system by ICU physicians and nurses, and integration of data systems and clinical information into the remote electronic ICU model. In this chapter, we will provide background information on error reduction theory and the role of the remote ICU model, review current data supporting use of the remote ICU system, address the current obstacles to effective implementation, and look to the future of the field for solutions to these challenges.

Paradoxical systemic air embolism (PAE) occurring as a complication of right-to-left intracardiac shunting during evaluation and treatment of pulmonary hypertension (PH) has not been previously reported. We report four cases of PH-associated PAE recently encountered at our center. Two patients with PH experienced transient neurologic deficits during agitated-saline contrast echocardiography (ASCE), and a patent foramen ovale was subsequently diagnosed in both patients. Two patients with Eisenmenger's syndrome (ES), while receiving epoprostenol via multilumen catheters, experienced transient neurologic deficits while flushing the unused port of the catheter. No patient experienced permanent neurologic deficits. We conclude that ASCE poses a risk for PAE in patients with PH and clinically silent, previously undetected, right-to-left intracardiac shunts, and that multilumen catheters used for long-term epoprostenol therapy in ES carry a risk of PAE.

Study Objectives: The aim of this study was to describe our experience at one institution with pulmonary veno-occlusive disease (PVOD) during the past 10 years, with particular reference to new findings and long-term outcome., Setting: Tertiary care, academic medical center., Patients and Methods: Eleven patients who were evaluated and treated for PVOD at our institution were retrospectively studied. Included were all available clinical, radiographic, hemodynamic, and pathologic data., Results: All 11 patients in our series had at least one symptom or clinical finding that, in conjunction with known pulmonary hypertension, suggested the diagnosis of PVOD. Digital clubbing, not previously reported in PVOD, was found in 5 patients, rales in 6, and increased interstitial markings on chest radiograph in 10. Half of the 10 patients who underwent acute vasodilator testing exhibited a decrease in pulmonary artery pressure of > 20%, although one patient died shortly after receiving IV calcium-channel blockers. Three patients have demonstrated sustained clinical improvement with therapy, which includes calcium-channel blockers, epoprostenol, and lung transplantation in one patient each. However, outcome was generally poor, with a 72% mortality within 1 year of diagnosis., Conclusion: The diagnosis of PVOD requires a high clinical suspicion. However, both physical examination findings and radiographic studies often provide clues to the diagnosis, which may obviate the need for lung biopsy in the majority of cases. Although there may be patients who respond to medical therapy, the use of vasoactive medications in patients with PVOD should be undertaken with great caution. Long-term survival is poor, and lung transplantation remains the only proven therapy.

A case of generalized melanosis complicating disseminated malignant melanoma in pregnancy is described. Four features of this case, unique in combination, are discussed. First, generalized melanosis is a rare complication in macrophages of skin and other areas. Secondly, extensive bone lesions in the absence of roentgenographic changes are an uncommon occurrence. Thirdly, pregnancy probably has little effect on the course of melanoma, as illustrated by this case and a review of the literature. Finally, placental metastases may be more common than generally thought, yet may have little significance to the fetus.