ICU Management Summer2015

02
COVER STORY: Cost-EffECtivEnEss
THE OFFICIAL MANAGEMENT AND PRACTICE JOURNAL VOLUME 15 - ISSUE 2 - SUMMER 2015
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ICU Management 2 - 2015

THE OFFICIAL MANAGEMENT AND PRACTICE JOURNAL VOLUME 15 - ISSUE 2 - SUMMER 2015
VISIT US
@Euroanaesthesia15,
#83b
COST-
EFFECTIVENESS
Lactate Monitoring Communicating About Difficult Medical
Early Sepsis Management Decisions
Moving From “Learning By Doing” To Partnering Medicine and Public Service

Simulation Country Focus: Korea
www.icu-management.org
EDITORIAL 49
COST-EFFECTIVENESS
I n medicine the benefits of treatment are always
weighed against possible harms. In these times
of budgetary constraints financial consider-
ations also come even more into focus. Cost-
effectiveness in medicine works at many levels. In
drugs that her hospital implemented, thus increasing
the protection of patients from falsified, expired
or recalled medicine.
In our Management section Alessandro Barelli,
Roberta Barelli, Antonio Gullì and Massimo Antonelli
clinical trials the cost of quality-adjusted life years describe the role of simulation in intensive care
(QALYs) may be one of the outcomes measured. education and training. Next, Peter Brindley explains
At a department or hospital level, directors need the basics of communicating about difficult medical
to consider the cost-effectiveness of staffing, decisions and outlines the communications tools
procedures or prescribing practices, for example. and bundles that can provide structure and reli-
Cost-effectiveness is pertinent when looking at ability to complex communication. He cautions,
introducing new treatments, but it is also a tool however, that they should never make interactions
to evaluate existing treatments and procedures. robotic and devoid of personal connection. Jean-Louis Vincent
In the first article in our cover story Diana Lebherz- Paul E. Pepe is interviewed for this issue. He
Editor-in-Chief
Eichinger, Barbara Gutenbrunner, Albert Reiter, looks back on 35 years of public service in emer- ICU Management
Georg A. Roth, Christian J. Herold and Claus Krenn gency medicine and the innovative research he
Head Department of
write about their study of the economic impact has conducted. He also expands on his mantra “a
Intensive Care
of omitting routine chest radiographs (CXR) in a gram of good pre-hospital care saves a kilogram
Erasme Hospital / Free
university ICU. They also conducted a prospective of ICU care” and what the definition of success University of Brussels
observational micro-costing exercise to identify is for an ICU director. Brussels, Belgium
the current costs of radiodiagnostic pathways, In my role as President of the World Federation
and compared the CXR cost calculation between of Societies of Intensive and Critical Care Medicine jlvincen@ulb.ac.be
a university hospital and a regional hospital ICU. (WFSICCM), I am looking forward to meeting
They argue that routine procedures should be many of you in Seoul for the WFSICCM congress
evaluated on their contribution to diagnosis, from 29 August – 1 September (an interview on
economic aspects and the patients’ benefit, and this role is on page 92). Korea is well-known for
that cost calculations should be regularly adapted the quality of its healthcare and contribution to
to reflect reality. Staying with imaging, next Diku the medical literature, and we are delighted to
Mandavia argues the case for ultrasound-guided feature Korea as our Country Focus. Dong Chan
needle procedures. He explains that ultrasound Kim, President of the Korean Society of Critical
guidance may significantly reduce serious adverse Care Medicine (KSCCM) and Sungwon Na, Secre-
events and the cost of care in patients. tary General of the KSCCM outline the past, the
In the Matrix section, Maarten Nijsten and Jan present and the future of critical care medicine
Bakker explain that the use of lactate measure- in Korea. Dong Chan Kim with Sang-Min Lee,
ments in critically ill patients is at a level where Director of Academic Board of the KSCCM write
in some cases it may be considered lactate moni- about hot topics in Korea, including the variance
toring. They discuss the central metabolic role of ICU treatment among institutions and the recent
of lactate in animal metabolism, why lactate is quality assessment that should improve the quality
mainly a marker of stress and how this trans- of ICU care further.
lates into its unique diagnostic utility in many As well as our Agenda listing upcoming inten-
acute conditions. They also look to a future role sive and critical care congresses, we include an
for computerised lactate decision support. Next, interview with Roger Harris from smacc (social
Jacqueline Pflaum-Carlson, Jayna Gardner-Gray, media and critical care), whose 3rd congress will
Gina Hurst and Emanuel P. Rivers review early be held in Chicago from 23-26 June.
sepsis management, concluding that the question
remains whether an invasive or noninvasive method As always, if you would like to get in touch,
(with or without central venous pressure) confers please email editorial@icu-management.org
improved mortality. Last, Heidi Wimmers writes
about the comprehensive traceability system for Jean-Louis Vincent

TABLE OF CONTENTS 51
ICU Management 54
COVER STORY: COST-EFFECTIVENESS
is the Official Management
and Practice Journal of the 54. Omitting Routine Chest Radiographs In Intensive Care Units: The Economic Impact
International Symposium on (Diana Lebherz-Eichinger, Barbara Gutenbrunner, Albert Reiter, Georg A. Roth, Christian J. Herold, Claus Krenn)
Intensive Care and Emergency
59. Ultrasound-Guided Procedures: Financial and Safety Benefits (Diku Mandavia)
Medicine and was previously
published as Hospital Critical Care.
Editor-in-Chief
Prof. Jean-Louis Vincent
Belgium 62
MATRIX
Editorial Board
62. Lactate Monitoring in the ICU (Maarten W.N. Nijsten, Jan Bakker)
Prof. Antonio Artigas 68. Early Sepsis Management (Jacqueline Pflaum-Carlson, Jayna Gardner-Gray, Gina Hurst, Emanuel P. Rivers)
spain
Prof. Jan Bakker
74. Why is Drug Traceability Important in a Hospital? Implementation at Hospital Alemán
netherlands in Argentina (Heidi Wimmers)
Prof. Richard Beale
United Kingdom
72
Prof. Rinaldo Bellomo
Australia
Dr. Todd Dorman

United states
Prof. Jan De Waele
Belgium
POINT-OF-VIEW
Dr. Bin Du 72. Rapid Pathogen Testing With PCR/ESI-MS (David Brealey)
China
Prof. Hans Kristian Flaatten
norway
76
Prof. Luciano Gattinoni
italy
Prof. Armand Girbes
netherlands
Prof. Edgar Jimenez MANAGEMENT
United states
Prof. John A. Kellum 76. Moving From “Learning By Doing” To Simulation: The Educational Challenge in Anaesthesia
United states and Intensive Care (Alessandro Barelli, Roberta Barelli, Antonio Gullì, Massimo Antonelli)
Prof. Jeff Lipman
Australia
80. Communicating About Difficult Medical Decisions: The Most Dangerous Procedure in the
Prof. John Marini Hospital? (Peter Brindley)
United states
Prof. John Marshall
84
Canada
Prof. Paul E. Pepe
United states
Prof. Paolo Pelosi
italy INTERVIEW
Dr. Shirish Prayag
india 84. Partnering Medicine and Public Service (Paul E. Pepe)
Prof. Peter Pronovost
United states
Prof. Konrad Reinhart
88
Germany
Prof. Gordon Rubenfeld
Canada
Prof. Eliezer Silva
Brazil COUNTRY FOCUS: SOUTH KOREA
Prof. Jukka Takala
switzerland
88. Critical Care Medicine in Korea - The Past, The Present And The Future (Dong Chan Kim, Sungwon Na)
90. Hot Topics In Critical Care Medicine In Korea (Dong Chan Kim, Sang-Min Lee)
Correspondents
Nathalie Danjoux
Canada EDITORIAL NEWS AGENDA
Prof. David Edbrooke 49.Cost-Effectiveness 52. Study Provides Guidance 92.World Federation of Societies of Intensive and Critical Care Medicine –
United Kingdom in EvERY (Jean-LouisVincent) For ICU Staffing InterviewWithWFSICCM President (Jean-LouisVincent)
Prof. Dr. Dominique Vandijck
Belgium
ISSUE Reducing the Risk of Recurrence 94. Smacc Chicago (Roger Harris) ICU Management 4 - 2014
of C. Diff Infection 96. Upcoming Events/Congresses
52
NEWS
Study Provides Guidance for ICU Staffing
The findings of a new study examining the ratio of nurse practitioners between 3 and 5 ICU patients, other factors that need to be considered
(NPs) and physician assistants (PAs) to patients may help hospital admin- include the patient’s severity of illness, the number of patients in the ICU,
istrators better determine appropriate staffing levels in ICUs. Published in the number of providers in the ICU, the patient’s diagnosis and care needs,
the American Journal of Critical Care (AJCC), “Patient-to-Provider Ratios for Nurse and the number of ICU admissions and discharges that may be occurring
Practitioners and Physician Assistants in Critical Care Settings: Results From at the same time, among others.
a National Survey” is the first national study to report on advanced practice
provider-to-patient ratios in ICUs and other acute and critical care settings. Is there any potential conflict between the roles of PAs and NPs? As NPs
The study was funded by the American Association of Critical-Care Nurses already have established educational routes in critical care, should PAs have
(AACN) through an Impact Research Grant, which supports clinical inquiry a similar educational programme?
that drives change in high acuity and critical care nursing practice. The roles of the NPs and PAs are not in conflict but are rather complementary.
The researchers collected 433 responses via an online survey of NPs and As advanced practice providers they similarly assist the intensivist-led team to
PAs who are members of the American Association of manage patients in the ICUs. However, their roles may vary
Nurse Practitioners, American Academy of Physician in that PAs may have a role in assisting in the operating
Assistants or the Society of Critical Care Medicine and theatre or in performing procedures while the NP may
practise in the U.S. and Canada. also have a role in providing education to the family and
Average provider-to-patient ratios reported were: nursing staff, implement quality improvement or research
• ICUs - 1:5 for both NPs and PAs; initiatives, or work on unit based guidelines. Working
• Paediatric ICUs - 1:4 for NPs; together with other members of the ICU team, NPs and
• Critical care settings that integrated fellows and PAs help to meet the workforce needs in the ICU.
medical residents - 1:4 for both NPs and PAs.
The researchers noted that the key factors that impact The expansion of NPs and PAs was a response to duty
patient-to-provider ratios are the severity of the patients’ hours regulations for physicians. Are existing regula-
illnesses, the number of patients in the unit and the tions sufficient on when and where to employ NPs
number of providers in the unit. Other factors include and PAs in the ICU?
patient diagnosis, the number of physicians in the unit, The resident duty hour restrictions are one factor that has
time of day and the number of fellows and medical led to increased use of NPs and PAs in the ICU. Other factors
residents on service. have included increased patient acuity levels; complex
Ruth Kleinpell, Rn-Cs, PhD, fCCM
To find out more about the study, ICU Management spoke care needs requiring care management and oversight;
to lead author, Ruth Kleinpell. the need to focus on improving quality of care metrics in
the ICU such as decreasing infection rates; implementing
Why was it important to gather this data and how will it help future guideline-based care, for example deep vein thrombosis prophylaxis or other
planning? care measures; and providing continuity of care.
More organisations are hiring NPs and PAs to assist in the management
of acute and critically ill patients as part of team-based care in the ICU. You write that “ensuring appropriate scope of practice is an essential aspect of
However, information is lacking on how NP and PA roles in the ICU are utilising NPs and PAs in the ICU.” How should scope of practice be addressed,
being developed and implemented, including the number of patients they for example in education and training, by professional associations, regula-
are overseeing as part of their roles in the ICU. The information provided in tory bodies or individual ICUs?
the survey can help ICU directors and others better develop staffing models Scope of practice is designated by the NP and PAs’ education and training. In
and structure roles for NPs and PAs in the ICU to work in conjunction with the United States, master’s degree education is required and some are seeking
the intensivist-led team. clinical doctorate level training in programmes that specifically focus on acute
Integrating NPs and PAs on the ICU team and assigning appropriate and critical care. Additionally, national certification is a requirement for most
workloads can ensure optimal care for ICU patients as well as promote U.S. states for NP practice, with NPs receiving certification as an acute care NP
recruitment and retention of qualified NPs and PAs. Their roles also promote to work in the ICU. PAs can seek a certificate of added qualification, commonly
continuity of care as, unlike rotating physicians, resident or fellows, their in emergency medicine, surgery or hospital medicine as one does not currently
consistent presence in the ICU can help to promote high quality care; exist for critical care. While a hospital’s credentialing and privileging process
promote patient, family and staff education; facilitate discharge planning; impacts NP and PA scope of practice, individual ICUs do not designate scope
and improve quality of care in the ICU. of practice. National credentialing boards and professional association specialty
competency guidelines are an additional reference source for defining scope
What are the next steps in establishing optimal ratios for ICUs for NPs of practice.
and PAs and the factors that affect these ratios?
Additional information is needed about NP and PA roles in the ICU. While Reference
the results of the study indicate that on average, they are helping to manage Kleinpell R, Ward ns, Kelso LA et al. (2015) Provider to patient ratios for nurse practitioners and
physician assistants in critical care units. Am J Crit Care, 24(3): e16-e21.

53
NEWS
Reducing the Risk of Recurrence of C. Diff Infection
A study published in JAMA has shown that drinking a non-toxic given a relatively higher dose of the good bug fared even better: only
strain of Clostridium difficile bacteria could help reduce the incidence two of 43 patients (5 percent) suffered another infection. Patients
of recurrent infection caused by the toxic strains of the bacteria. on the therapy had headaches more often than the placebo group,
C. difficile is the most common cause of healthcare-associated infec- but there was no evidence of serious risks, the research team noted.
tion in U.S. hospitals, and recurrence occurs in 25 to 30 percent of After treatment, the good C. difficile bacteria "don't stay around
patients. Toxic strains of C. difficile bacteria cause diarrhoea, abdominal forever," Dr. Gerding said, adding that the therapy may set the stage
cramps and, in some cases, severe inflammation of the colon. The for patients' normal balance of gut bacteria to flourish again.
infection commonly affects people during or after a hospital stay, In an interview with ICU Management Dr. Gerding explained that
particularly those who have had a long course of antibiotics or have non-antibiotic treatment was the focus as the antibiotics used to treat
a weakened immune system. the C. difficile infection leave the patients susceptible for reccurrence
"The antibiotics don't completely get rid of the C. diff bacteria, because they disrupt the normal bacteria in the gut. A mechanism
and if the patient hasn't developed an immune response against the for treating it was needed that doesn’t affect the other bacteria in
toxin the bacteria produces, they'll get sick again," explained lead the gut so the study substituted the non-toxigenic strain for the
author Dale Gerding, MD, professor of medicine at Loyola University toxigenic strain, getting the gut colonised with the non-toxigenic
Chicago Stritch School of Medicine. strain and then preventing patients from having the reccurrence.
In this trial, after patients were successfully treated with an antibiotic, Dr. Gerding confirmed that a phase three trial is planned to look at
the researchers gave them a non-toxic strain of C. difficile, theorising the optimal dose and duration of the therapy. Looking to the future, as
that the good bug would crowd out what remained of its toxic it is easy to identify who is most at risk of C. diff infection, treatment
cousin. 173 patients (18 years or older) were randomly assigned would simply be an adjunct treatment to prevent patients getting a
to four groups: three that received different doses of non-toxic C. recurrence and ultimately for primary prevention.
difficile, and one that was given a placebo. The good C. difficile, Dr.
Gerding noted, is completely natural. Treatment involved drinking Reference
a colourless, odourless liquid once a day, for one week. Gerding Dn, Meyer t, Lee C et al. (2015) Administration of spores of nontoxigenic clostridium
difficile strain M3 for prevention of recurrent C difficile infection: a randomized clinical trial.
Of 125 patients who received the treatment, only 11 percent had
JAMA, 313(17): 1719-27.
a recurrent infection within six weeks. Notably, a subgroup that was
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54
OMITTING ROUTINE CHEST RADIO-

GRAPHS IN INTENSIVE CARE UNITS
THE ECONOMIC IMPACT
We studied the economic impact of omitting routine chest radiographs (CXR) in a university ICU. Additionally,
we performed a prospective observational micro-costing exercise to identify the current costs of radiodiagnostic
pathways, and compared the CXR cost calculation between a university hospital and a regional hospital ICU.
Diana Lebherz-Eichinger,
MD, MSc
Resident
A nteroposterior chest radiographs
(CXRs) are often obtained daily
from patients in intensive care units
(ICUs) in addition to a physical examina-
tion (Godoy et al. 2012; Trotman-Dickenson
cost savings without degrading the quality
of medical care (Price et al. 1999). The aim
of this study was to analyse the real costs
of radiodiagnostic pathways in ICUs and
investigate the potential cost savings due
Department of Anesthesiology,
General Intensive Care and Pain 2003). The detection of complications asso- to the elimination of routine CXRs and the
Medicine ciated with indwelling devices as well as restriction of radiographs to specific clinical
Medical University of Vienna
the timely recognition of cardiopulmonary indications.
Vienna, Austria
afflictions can lead to earlier treatment of
diana.lebherz-eichinger@
meduniwien.ac.at clinically unsuspected problems. Therefore Materials and Methods
various guidelines recommend routine CXRs, Study Design
especially in patients receiving mechanical The study was planned in three parts. First we
ventilation or suffering from acute cardio- performed a prospective observational micro-
pulmonary disorders (Amorosa 2008). In costing exercise for one week in five ICUs at the
Barbara Gutenbrunner, contrast, a more restrictive approach limits university hospital of Vienna, Austria, to analyse
MD CXRs to specific clinical indications like the current costs of radiodiagnostic pathways.
Resident placement of indwelling devices or a change During this period daily routine CXRs were
Department of Anesthesiology and in the patient’s respiratory status (Clec'h et obtained from every patient admitted. The
Intensive Care
Landesklinikum Amstetten
al. 2008; Graat et al. 2006; Graat et al. 2007; requirements of personnel and consumable
Amstetten, Austria Hejblum et al. 2009; Hendrikse et al. 2007; materials to obtain radiographs were assessed
barbara.gutenbrunner@icloud.com Krivopal et al. 2003; Silverstein et al. 1993). and compared with the corresponding cost
Diana Lebherz-Eichinger and Barbara
Gutenbrunner contributed equally to Those studies have questioned the medical accounting. Through pathway construction
this work Albert Reiter, MD benefit of routine CXR in ICU patients. each process of radiodiagnostic examination
Head of the Department of Anesthe- Furthermore, restrictions in performing (RDE) was individually analysed in order to
siology and Intensive Care
Landesklinikum Amstetten
CXRs in ICUs may help to decrease healthcare charge overall costs by activity-based costing.
Amstetten, Austria costs, reduce radiation exposure, and avoid Secondly, the application and costing of CXRs in
unnecessary treatment of minor or false posi- the university hospital and a regional hospital
Georg A. Roth, MD tive findings (Brainsky et al. 1997; Fong et al. (Landesklinikum Amstetten, Lower Austria,
Associate Professor
Department of Anesthesiology, 1995; Hendrikse et al. 2007; Krivopal et al. Austria) were compared to reveal differences in
General Intensive Care and Pain 2003; Leppek et al. 1998; Price et al. 1999). CXR cost accounting and application manage-
Medicine Also the positioning of critically ill patients ment. Thirdly, we analysed cost savings due to
Vienna, Austria
can lead to adverse events like malpositioning elimination of daily CXRs in a university ICU,
of devices, which also can be minimised by including data on all admitted patients, six
Christian J. Herold, MD the strict limitation of radiographs to partic- months before and six months after routine
Univ.-Professor
ular clinical indications (Boulain 1998). CXRs were eliminated. All costs are given in
Head of the Department of Radiology
Medical University of Vienna Economic and clinical costs associated Euros.
Vienna, Austria with routine CXRs have to be taken into
account. In general, avoidable costs should Study Locations
Claus Krenn, MD
Ao. Univ.-Professor
be minimised, without limiting diagnostic The micro-costing study was conducted in
Department of Anesthesiology, quality, to ensure an optimal distribution of five ICUs of the university hospital of Vienna,
General Intensive Care and Pain financial resources. Hence the omission of Austria. Each ICU is an 8-bed closed-format
Medicine routine CXRs in ICUs can lead to substantial department (4 sickrooms each) in which
Vienna, Austria

55
medical and surgical patients (including cian, was documented by the radiologist on Regional University hospital
cardiothoracic surgery and neurosurgery duty. The data retrieved was compared with hospital
first second
patients) are under the direct care of the the correspondent in-house cost accounting. first half-year half-year half-year
ICU team. During daytime the patients of one No. of patients 80 248 258
ICU are under the observation of up to two Before-After Study
No. of patients
ICU physicians and residents. At night or at Between January and June 2010 the number 10 31 32
per bed
the weekend the on-call ICU team comprises of CXRs was retrospectively assessed for all
Age (years, mean,
one ICU physician and one resident. patients in one university ICU as well as in 63 (19) 60 (16) 57 (18)
SD)
In Amstetten hospital the ICU is an 8-bed the ICU in the tertiary hospital of Amstetten.
closed-format department with medical and The number of treated patients, their length Gender male (n, %) 49 (61%) 146 (59%) 168 (6 %)
surgical patients. Cardiothoracic surgery of stay and intensive scores were collected Length of stay/
and neurosurgery are not performed in this and compared between locations. At that time patient in ICU 12.7 (14) ** 5.8 (6) 5.6 (9)
hospital. The ICU team comprises one physi- daily CXRs were standard procedure in the (days, SD)
cian and one resident during the day and one university ICU, and for ventilated patients SAPS II score 32.2
31 (13.2) 32.9 (13.6)
physician during the night or at the weekend. only in Amstetten. (mean, SD) (15.1)
In the second half-year period, CXRs in Non-survivor (n, %) 25 (20%)** 17 (7 %) 25 (1%)
Micro-costing the university ICU were limited to specific
No. of CXRs 751 1254 828
To estimate the costs of RDEs in university indications, e.g. the insertion of indwelling
ICUs each process was individually analysed devices, an increase in oxygen requirement, CXRs per patient 9.4 5.1 3.2
by activity-based costing. The personnel or in pulmonary secretion. CXRs at admis- CXRs per patient
0.7 1.1 0.6
requirement as well as the consumable sion were conducted only if in the short- per day
material was reported via questionnaires, term no previous radiograph was available Estimated costs
23.36 54.30 54.30
which were completed for every obtained or after insertion of central venous lines. per CXR (Euro)
CXR by the staff involved. This observational Daily CXRs were performed in accordance Costs for CXRs/
218.7 274.6 174.3
phase was conducted over one week in five with the guidelines of the Royal College patient (Euro)
ICUs at the university hospital of Vienna, of Radiologists (2003). For this period the Costs for CXRs/
19.2 57.2 34.2
Austria. At that time daily routine CXRs number of CXRs and the patients’ data were patient/day (Euro)
No. of CT 145 97
“Restrictions may help to decrease costs, reduce radia- Patient subgroups
Medical (n) 30* 50 56

tion exposure and avoid unnecessary treatment of minor Cardiovascular
2 21 22
surgery (n)
or false positive findings” Neurosurgery (n) 11 6
Thoracic surgery (n) 12 11

were standard procedure and the data were also collected as for the first half-year 2010. Transplantation (n) 11 9
collected for every patient receiving a CXR Furthermore, the number of computed
within the study week, including repeated tomography (CT) scans on demand was Trauma (n) 28** 23 20
radiographs for the same patient. The ques- assessed separately for the two periods in Gastrointestinal
20* 32 46
tionnaires comprised the number and the order to assess a potential change in the surgery (n)
qualifications of all involved employees as usage of other imaging techniques. Other (n) 49 60
well as the consumable material used and Unknown (n) 39 28
the time needed to obtain the individual Statistical Analysis
CXRs (including the time needed to cart Demographic data were extracted from the Table 1. Demographic Data
the mobile x-ray apparatus from the base to ICU databases. Data are expressed as mean Asterisks depict the significance compared to data of the university
the first ICU, from one unit to another and and standard deviation unless otherwise hospital in the first half-year (* p < 0.01; ** p < 0.001). the patients did
not differ significantly in age, sex or sAPsii score between all compared
between sickrooms). The patients’ diagnosis stated. Statistical analysis was performed with groups. the patients admitted in the first and the second half-year 2010
and treatment, including respiratory status GraphPad Prism Version 5.01 (GraphPad Soft- to the university iCU did not differ between the patients’ subgroups or
mortality.
and extracorporeal circuits, were docu- ware, Inc. San Diego, CA, USA). Demographic
sAPs ii, simplified Acute Physiology score; CXR, Anteroposterior chest
mented separately. Patients suffering from data of patients admitted to Amstetten or to radiographs.
infectious diseases were described in partic- the university ICU in the second half-year
ular, due to the increased effort to obtain the 2010 were statistically compared to patients
CXR. Further, the time needed to examine admitted to the university ICU in the first
every individual radiograph, including the half-year 2010. The numbers of patients in the
diagnosis and discussion with the ICU physi- patients’ subgroups, the numbers of survivors,

56
and the number of males/females were compared an x-ray film per CXR - although the CXRs mortality or length of ICU stay (see Table 1).
with X² analysis, with p < 0.05 considered signif- were already saved digitally at that time - but Since real costs could not be determined
icant. The patients’ age and SAPSII score as well as no further consumable material necessary. by our study the charges set by the finance
their length of ICU stay were analysed with the department were used for cost saving calcula-
two-tailed Mann-Whitney U test, with p < 0.05 University hospital versus regional tion. As 54.30 Euro were estimated per CXR
considered significant. hospital by the finance department, the decreased
Within the same time period 78 patients usage of radiographs led to a calculated
Results were admitted to the regional ICU versus 248 cost reduction of about 23,000 Euro. The
Micro-Costing patients in the university ICU. The patients daily costs for radiographs per patients per
During the study period the time to obtain were comparable in age, sex, and severity day dropped from 57 Euro to 34 Euro. Total
a CXR was measured for 46 patients, and of disease, but differed in length of stay and cost savings amounted to about 100 Euro
the examination time was documented for mortality (see Table 1). per patient (see Table 1). Interestingly, the
41 patients by the radiologist on duty. 19 Amstetten charged 23.36 Euro per CXR number of demanded CT interventions also
patients were mechanically ventilated via consisting of 10 minutes working time for decreased from 145 in the first half-year to
tube and five patients were infected with two technicians, consumable material, initial 97 in the second half-year, leading to a calcu-
lated cost reduction of about 13,500 Euro, as
280.11 Euro were charged per CT examina-
“Routine procedures should be questioned on their contri- tion by the finance department.
bution to diagnosis, economic aspects, and patients’ Discussion

benefit” CXRs are frequently obtained daily to early
detect cardiopulmonary complications in

patients admitted to ICUs. In contrast, recent
a multiresistant pathogen. Every CXR was costs as well as costs of upkeep, administra- publications question the diagnostic and
obtained by a technician. If the patient was tion, and electricity. The medical examination clinical value of routine RDEs (Clec'h et al.
mechanically ventilated additional help from was not accounted. In the university hospital, 2008; Graat et al. 2006; Graat et al. 2007;
the nursing staff present were necessary. The the finance department estimated a charge Hendrikse et al. 2007; Kappert et al. 2008;
examination and discussion was conducted of 54.30 Euro per CXR, which included the Price et al. 1999). Those studies demon-
by a resident of radiology and a resident of medical examination. strated that daily CXRs rarely reveal clini-
intensive care medicine. However, the offi- Additional costs, such as depreciation of cally relevant abnormalities. Furthermore, the
cial in-house cost accounting considered a capital goods like the radiologic scanner, the omission of routine CXRs had no effect on
technician to obtain the CXR as well as an printer or the x-ray viewing screen, were the patients’ outcome or readmission rate,
assistant, whose help was essentially not not specified in both hospitals. Unlike the but led to cost savings and economic benefits.
required. On the contrary, the intervention university hospital, the finance depart- Clec’h et al. were even able to demonstrate
of the nursing staff was not accounted for. ment in Amstetten differed between CXRs that the restrictive usage of CXRs was associ-
The official cost accounting included one obtained from ICU patients or out-patients. ated with better diagnostic and therapeutic
medical doctor to examine the CXR, without Daily costs for CXRs per patients accounted efficacy than daily routine use (Clec'h et al.
appraisal of his/her qualifications. for 19.2 Euro in the regional hospital in 2008). Based on those findings we analysed
The account of time taken shows that all contrast to 57.2 Euro in the university the financial impact of omission of routine
radiodiagnostic measures within one univer- hospital. Charges for one patient amounted CXRs in a university ICU. Further, we inves-
sity ICU lasted 24 minutes and the examina- to a total of about 200 Euro in Amstetten tigated each process of RDEs via pathway
tion for all patients within one university versus 270 Euro in Vienna. construction and compared the cost calcu-
ICU 13 minutes. lation with real time and effort measured.
The finance department computed the Before-after study In most European countries healthcare
following working time for one CXR: 25 In the first half-year 2010 (1 January-30 costs are usually not borne by the indi-
minutes for a technician, 5 minutes for a June) 1254 CXRs were obtained from 248 vidual patient but by health insurance. As a
medical doctor and 10 minutes for an assis- patients in the university ICU (see Table 1). consequence, economic pressure to change
tant, whose help was essentially not required. In the second half-year (1 July-31 December) routine examinations is barely present as
The consumable material to obtain CXRs daily routine CXRs were abandoned and long as the patients’ security is assured.
from non-infectious patients comprised radiographs were limited to specific indi- Due to daily changes in medical personnel,
disinfection material, disposable gloves cations. During this period 828 CXRs were routine CXRs have been standard procedure
and aprons. For patients suffering from obtained from 258 patients, a reduction of in our department in order to compensate
multiresistant pathogens surgical masks, 34%. From January till June 5.1 CXRs per for potential deficits in medical handover.
surgical caps, surgical coats, and wrapping patients were performed, versus 3.2 from Because of emerging economic pressure,
for the x-ray film cartridge were additionally July till December. Apparently the reduction traditional procedures like routine RDEs have
needed. The official cost accounting deemed of radiographs had no effect on the patients’ been increasingly questioned, leading to the

58
omission of daily CXRs in our ICU. As a result, Our analyses of RDEs by activity-based RDEs were restricted to clinical indications.
the limitation of RDEs to defined clinical indi- costing via pathway construction revealed a The patient population was comparable in
cations caused a reduction of radiographs of mismatch between accounted and real costs. age, sex, and severity of disease, but differed
34% within six months. Thereby the analysed We demonstrated that RDEs in ICUs are less in patient subgroups and consequently in
before and after patient cohorts were compa- time-consuming than expected, even when length of ICU-stay and the patients’ mortality.
rable, with no statistical significance in age, the patients were mechanically ventilated or Due to their longer hospitalisation, patients
sex or severity of illness. In accordance with infectious. Working time, the most impor- in the regional hospital received more CXRs.
the literature we also could not observe any tant cost item, was overestimated in the
differences in mortality or in length of ICU official cost calculation by about 90%. This Conclusion
stay attributed to the omission of daily CXRs. difference in charged and real working time Our study demonstrates the substantial
Since daily radiodiagnostic controls were not might derive from preset values, which have impact that changes in routine tests and
available any more, the number of ordered CT been used for cost calculations. Although clinical management may have on economic
interventions might subsequently have been radiographs were saved digitally at time costs. Therefore routine procedures should be
increased in order to overcome this limitation. of investigation, the cost accounting still regularly questioned on their contribution to
Interestingly the number of CT examinations calculated CXR costs based on x-ray films diagnosis, economic aspects and the patients’
even decreased, which is in accordance with but no consumable material, energy costs benefit to enable an optimal distribution of
the study of Kröner et al., who showed that or additional charges. Thus, accounting costs resources. Moreover, cost calculations should
limitation of daily radiographs had no impact do not correlate with real effort, but unfor- be regularly adapted to reflect the real use
on number or implication of CT and ultra- tunately we were not able to ascertain real of resources.
sound examinations (Kroner et al. 2008). costs within this study.
The omission of daily routine CXRs in In the regional hospital CXR cost calcula- Acknowledgements
the university hospital led to calculated tion differed from the university hospital. We are indebted to Prof. Judith Simon for
cost savings of about 23,000 Euro within Cost accounting in the regional hospital critically reviewing our manuscript. There
six months for one 8-bed ICU. Daily CXR was more accurate and even differentiated are no actual or potential conflicts of interest
charges per patients were reduced by half, between patients admitted to ICUs and out- capable of influencing judgment on the part
resulting in an overall cost saving of about patients. In contrast, medical appraisal of of any of the authors.
100 Euro per patient. This is in accordance findings was not considered in CXR cost
with Price et al., who also demonstrated the calculation. In the regional as well as in
financial impact of an evaluation and subse- the university hospital charges for capital
quent change in CXR ordering practice in a goods such as the radiologic scanner, the
paediatric ICU, leading to fewer radiographs printer and x-ray viewing screens were not
per patients and consequently to cost reduc- accounted for in CXR cost calculation and
tion (Price et al. 1999). The reduced demand might therefore have been included else-
of CT examinations in our ICU resulted in where. In the regional hospital, daily CXRs
cost savings of about 13,500 Euro for a time were standard procedure for ventilated
period of six months. patients only, whereas for other patients
References Utility of routine chest radiographs in the Hendrikse KA, Gratama JW, Hove W et al. al. (1998) Radiation exposure during thoracic
surgical intensive care unit. A prospective (2007) Low value of routine chest radiographs radiography at the intensive care unit. Dose
Amorosa JK, Bramwit MP, Khan AR et al. study. Arch surg, 130(7): 764-8. in a mixed medical-surgical iCU. Chest, accumulation and risk of radiation-induced
(2008) ACR appropriateness criteria: routine 132(3): 823-8. cancer in long-term therapy. Radiologe,
chest radiograph. Reston, vA: American College Godoy MC, Leitman Bs, de Groot PM et al.
(2012) Chest radiography in the iCU: Part Kappert U, stehr sn , Matschke K (2008) Effect 38(9): 730-6.
of Radiology.
1, evaluation of airway, enteric, and pleural of eliminating daily routine chest radiographs Price MB, Grant MJ , Welkie K (1999) financial
Boulain t (1998) Unplanned extubations in tubes. AJR Am J Roentgenol, 198(3): 563-71. on on-demand radiograph practice in post- impact of elimination of routine chest radio-
the adult intensive care unit: a prospective cardiothoracic surgery patients. J thorac graphs in a pediatric intensive care unit. Crit
multicenter study. Association des Reanima- Graat ME, Choi G, Wolthuis EK et al. (2006) the
clinical value of daily routine chest radiographs Cardiovasc surg, 135(2): 467-8. Care Med, 27(8): 1588-93.
teurs du Centre-ouest. Am J Respir Crit Care
Med, 157(4 Pt 1): 1131-7. in a mixed medical-surgical intensive care Krivopal M, shlobin oA , schwartzstein RM Royal College of Radiologists (2003) Making
unit is low. Crit Care, 10(1): R11. (2003) Utility of daily routine portable chest the best use of a department of clinical radi-
Brainsky A, fletcher RH, Glick HA et al. (1997) radiographs in mechanically ventilated patients ology: guidelines for doctors. 5th ed. London:
Routine portable chest radiographs in the Graat ME, Kroner A, spronk PE et al. (2007)
Elimination of daily routine chest radiographs in the medical iCU. Chest, 123(5): 1607-14. Royal College of Radiologists.
medical intensive care unit: effects and costs.
Crit Care Med, 25(5): 801-5. in a mixed medical-surgical intensive care unit. Kroner A, Binnekade JM, Graat ME et al. silverstein Ds, Livingston DH, Elcavage J et
intensive Care Med, 33(4): 639-44. (2008) on-demand rather than daily-routine al. (1993) the utility of routine daily chest
Clec'h C, simon P, Hamdi A et al. (2008) Are chest radiography prescription may change radiography in the surgical intensive care
daily routine chest radiographs useful in criti- Hejblum G, Chalumeau-Lemoine L, ioos
v et al. (2009) Comparison of routine and neither the number nor the impact of chest unit. J trauma, 35(4): 643-6.
cally ill, mechanically ventilated patients? A computed tomography and ultrasound studies
randomized study. intensive Care Med, 34(2): on-demand prescription of chest radiographs in trotman-Dickenson B (2003) Radiology in the
mechanically ventilated adults: a multicentre, in a multidisciplinary intensive care unit. intensive care unit (Part i). J intensive Care
264-70. Anesthesiology, 108(1): 40-5.
cluster-randomised, two-period crossover Med, 18(4): 198-210.
fong Y, Whalen Gf, Hariri RJ et al. (1995) study. Lancet, 374(9702): 1687-93. Leppek R, Bertrams ss, Holtermann W et

59
ULTRASOUND-GUIDED PROCEDURES
FINANCIAL AND SAFETY BENEFITS
Ultrasound Guidance Improves as $56,000 per infection (O’Grady 2011; Diku Mandavia, MD,
the Safety and Success of Needle O’Grady 2002). Collapsed lung increases FACEP, FRCPC
Procedures length of hospital stay by 4 to 7 days at an Chief Medical Officer
SonoSite, Inc.
The European Prevalence of Infection in additional cost of up to US$45,000 per case
Intensive Care study reported that 78% (Zhan 2004). Clinical Associate Professor
of Emergency Medicine
of critically ill patients had a central line Yet there are proven safety practices to
University of Southern California
inserted, while several million central reduce or even eliminate these serious, but Los Angeles, CA, USA
venous catheters (CVCs) a year are placed preventable complications. In a randomised
diku.mandavia@sonosite.com
in American hospitals (Gibbs, 2006). Since controlled trial (RCT) of 900 critical care
this common procedure can have serious patients, ultrasound-guided CVC placements
risks, including accidental puncture and in the internal jugular vein lowered rates of
collapse of the patient’s lung (iatrogenic pneumothorax to zero percent, compared to
pneumothorax), arterial injury, haemorrhage a rate of 2.4% for landmark methods (Kara-
and even death (Bowdle, 2014), it is crucial kitsos 2006). The study also reported the
that the catheter be placed correctly, with as following outcomes: practice if ultrasound guidance is available at
few attempts as possible. • A 100% success rate with ultrasound- that hospital” (Bodenham 2011).
Traditionally clinicians have used anatomic guided CVC placement, compared to A Cochrane systematic review by German
‘landmarks’ to estimate where the target 94.4% in the landmark group; and British researchers found striking
blood vessel lies below the skin. However, • A 0.6% rate of haematoma with ultra- safety benefits for ultrasound-guided CVCs
this method can be unsuccessful in up to sound, versus 8.4% without it; of the internal jugular vein (Brass 2015),
35% of cases (Bernard 1971; Defalque • A 1.1% rate of accidental carotid artery compared to the landmark method. Key find-
1974; Sznajder 1986), with complication puncture with ultrasound, versus 10.6% ings from an examination of pooled data
rates of up to 19% reported in the literature with landmark methods; from 35 studies involving 5,108 participants
(Merrer 2001). Moreover, 9% of patients • The ultrasound arm also had significantly included the following reductions in adverse
have anatomic abnormalities of their central reduced blood vessel access time, higher events and improvements in procedure
veins, making CVC placement difficult, first-pass success, and a 35% lower rate success in the ultrasound group:
dangerous or even impossible (Denys 1991). of central line-associated bloodstream • 71% reduction in total complications
Ultrasound guidance allows clinicians to infection (CLASBI). (14 trials, 2,406 participants);
see their anatomical target and surrounding Similarly, in a recent RCT of ultrasound • 72% reduction in accidental arterial
structures, such as soft tissue, vessels and versus ‘blind’ landmark technique for place- puncture (22 trials, 4,388 partici-
nerves in real time as the needle advances to ment of subclavian lines, patients whose CVCs pants;
the procedure’s endpoint, instead of working were inserted under real-time ultrasound • 73% decrease in haematoma forma-
blindly. In addition, ultrasound visualisation guidance had zero percent rates of pneumo- tion (13 trials, 3,233 participants);
can also help clinicians assess the patency thorax and haemothorax, compared to rates • 57% higher first-attempt success rate
and diameter of the target vein. of 4.8 and 4.4 % in the landmark group (18 trials, 2,681 participants);
(Fragou 2011). All other adverse events were • Significantly faster time to perform
Ultrasound Helps Reduce Procedural also reduced or eliminated when ultrasound the procedure.
Errors and Costs visualisation was used. In this cohort of crit- Indeed, the safety data is so overwhelming
Central line-associated bloodstream infec- ical care patients, successful cannulation was that in 2002 the United Kingdom’s National
tions (CLASBIs) and pneumothorax rank achieved in 100% of the ultrasound group, Institute for Health and Clinical Excellence
among the six most expensive medical compared with 87.5% of the landmark arm. (NICE) formulated guidelines advising ultra-
errors (Van Den Bos 2011). According to Based on these outcomes, an accompanying sound guidance as the preferred method to
the Centers for Disease Control (CDC), editorial by Andrew Bodenham suggested that, lower the risk of iatrogenic pneumothorax,
about 250,000 CLASBIs infections occur “there is now enough evidence for the bene- arterial puncture, arteriovenous fistula, nerve
each year in the United States with attrib- fits of ultrasound for it now to be considered injuries and other complications (NICE 2002). An
utable mortality estimated at 12 to 25% and unethical to continue to submit patients to economic model developed by NICE’s assessment
attributable cost estimated to range as high the risks of landmark techniques for research group also suggested that ultrasound guidance was

60
“both more effective and less costly than the 5. Daily review of CVC line necessity, with • Faster vascular access (13 minutes with
landmark method.” prompt removal of unneeded lines; ultrasound guidance versus 30 minutes
Now the standard of care in the UK, ultra- 6. Ultrasound-guided line placement. without it);
sound-guided CVC placement is also endorsed • Fewer percutaneous punctures with ultra-
as the preferred practice by the Agency for Ultrasound-Guided Peripheral IV sound guidance (1.7 versus 3.7 with land-
Healthcare Research and Quality (AHRQ 2001), Access as an Alternative to High- mark methods);
the CDC and in related guidelines from many Risk CVCs • Greater patient satisfaction when ultra-
medical societies, including the American Board Establishing vascular access is one of the most sound was used.
of Internal Medicine, the American Society of commonly performed hospital procedures, with
Anesthesiologists, and the American College of speed and success rate particularly critical to Safer, More Cost-Effective
Chest Physicians, among others. optimal care of critically ill and unstable patients. Thoracentesis and Paracentesis
However, failure rates of emergent peripheral Ultrasound guidance may significantly reduce
Best Safety Practices to Prevent intravenous (PIV) access of 10 to 40% have been serious adverse events and the cost of care in
Hospital Infections reported in the literature, with the average time patients undergoing two commonly performed
Healthcare-associated infections (HAI) are now needed for PIV reported at 2.5 to 13 minutes, needle procedures: thoracentesis (draining fluid
the most common adverse event affecting hospi- and difficult PIV access taking up to 30 minutes from the chest) and paracentesis (draining fluid
talised patients, with about 30% of those in the (Leidel 2009). from the abdomen), according to a recent study
ICU suffering one or more HAIs, according to
the World Health Organization (WHO) (n.d.). In
the European Union, about 4.1 million patients “Ultrasound-guided needle procedures can significantly
fall victim to these infections annually, killing
enhance the safety and quality of patient care, while
about 37,000 patients and contributing an addi-

tional 110,000 deaths each year, reported by helping reduce costs and complications”
the European Centre for Disease Prevention and
Control (ECDC) (2015).
CLASBIs rank among the leading HAIs, and Difficult PIV access may occur due to such (Mercaldi 2013). The study examined data from
major initiatives to combat these dangerous factors as obesity, history of IV drug use, chronic the national Premier Prospective automated
infections have been launched in both Europe illness, chemotherapy or vascular pathology hospital database, with the following results,
and the U.S. For example, the European Commis- (Leidel 2009; Crowley 2011), and can lead after adjustment for possible confounding factors:
sion has funded the PROHIBIT (Prevention of to significant delays in essential treatment for • For the 61,261 patients who underwent a
Hospital Infections by Intervention & Training) seriously ill patients who need it the most. In thoracentesis, ultrasound guidance reduced
study, in which the ICUs of 14 participating this situation, clinicians often use CVCs as an the rate of pneumothorax by 19%. When
hospitals implemented a bundle of CVC safety alternative. collapsed lung occurred, this complica-
practices, including improved hand hygiene Ultrasound-guided PIV may prevent many tion raised the patient’s hospital cost to
(WHO 2015). unnecessary central line placements in patients US$13,784, compared to $11,032 for
In the U.S. a sustained reduction (of up to with problematic IV access. In a study involving a patient who didn’t suffer a collapsed
66%) in CLASBIs occurred over 18 months in 100 emergency department (ED) patients with lung. In addition, the mean length of
103 participating ICUs after a five-point bundle difficult vascular access, ultrasound-guided PIV hospital stay was 7.9 days for a patient
of evidence-based CVC safety practices was access eliminated the need for CVC placements with a pneumothorax, versus 6.5 days for
implemented (Pronovost 2006). Now there is in 85% of cases (Au 2012). These patients were a patient without it.
a growing movement to add a sixth element to tracked for seven days, with a zero percent rate • For the 69,859 patients who underwent a
the bundle: the use of ultrasound guidance for of complications. paracentesis—often a challenging proce-
central line placement. Given that CVCs can have a complication rate dure to perform with blind landmark
Hospitals that have implemented this approach, of up to 15% (Feller-Klopman 2007), with methods—ultrasound guidance lowered
including Cedars-Sinai Medical Center in Los estimated costs ranging as high as US$50,000 the rate of bleeding complications,
Angeles, California, have seen striking reduc- per case (Fraenkel 2000), the study’s outcomes such as haemorrhage, haematoma, and
tions in CLASBIs, while White Memorial Medical suggest that wider use of ultrasound-guided haemoperitoneum, by 68%. A bleeding
Center in Los Angeles was able to achieve a rate PIVs could yield substantial improvements in complication raised hospital costs to
of zero between January 2010 and August 2011 patient safety with a significant reduction in nearly US$30,000, about triple the cost
at the 353-bed hospital. The six-point bundle ED costs. Another study of ultrasound-guided for a patient without this adverse event
used consisted of these components: PIVs in difficult-access ED patients reported a ($9,476), and nearly doubled length of
1. Hand hygiene; 97% success rate, compared to only 33% when hospital stay, from a mean of 5.2 days for
2. Maximal barrier precautions; traditional landmark approaches were used a patient without a bleeding complication
3. Chlorhexidine skin antisepsis; (Constantino 2005). The study also reported to a mean of 9.5 days for a patient who
4. Optimal catheter site selection; the following results for the ultrasound group: suffered one.

61
Ultrasound at the bedside can also help eliminate As we strive to improve healthcare and rein invasive procedures performed to help
the risks and costs of unnecessary procedures. In in costs, physician leaders and hospital patients heal. Ultimately, it is the sickest
one study, 100 patients with suspected ascites were administrators should carefully weigh the patients who will benefit the most from a
randomised to receive paracentesis with landmark many benefits of ultrasound at the bedside best-practice approach that leads to optimal
or bedside ultrasound-assisted techniques (Nazeer for reducing the risk of medical harm from outcomes.
2005). In the landmark arm, 61% of the proce-
dures were successful. In the ultrasound group
paracentesis was found to be unnecessary in 25%
of the patients. In patients who actually needed Key Messages central line insertions, paracentesis
fluid aspiration, ultrasound-guided paracentesis and thoracentesis.
• Evidence-based guidelines from
was successful in 95% of cases. • Use of ultrasound-guided peripheral
many medical societies recommend
ultrasound-guided central venous intravenous catheters may prevent
Conclusion catheter (CvC) placement as an the need for high-risk CvCs.
Robust evidence from multiple studies demon- important safety practice. • Ultrasound at the bedside has
strates that ultrasound-guided needle procedures
• Compared to landmark techniques, become an increasingly valuable tool
can significantly enhance the safety and quality across hospital departments for a
ultrasound guidance can significantly
of patient care, while helping reduce costs and variety of applications, while sparing
reduce medical errors and costs of
complications. The reason is simple: just as radar patients health risks associated with
needle-based procedures commonly
helps airline pilots navigate safely to the right ionising radiation.
performed in critical care, including
destination at night, ultrasound visualisation
allows clinicians to see their anatomical target,
instead of working blindly.
References Med, 42(3): 218-23. saf surg, 3(1):24. related bloodstream infections in the iCU.
European Centre for Disease Prevention Mercaldi CJ, Lanes sf (2013) Ultrasound n Engl J Med, 355(26): 2725-32.
Au AK, Rotte MJ, Grzybowski RJ et al. (2012)
Decrease in central venous catheter place- and Control (2015) Healthcare-associated guidance decreases complications and shojania KG, Duncan BW, McDonald KM et
ments due to use of ultrasound guidance infections. [Accessed 24 April 2015] Available improves the cost of care among patients al. (2001) Making health care safer: a critical
for peripheral intravenous catheters. Am from http://ecdc.europa.eu/en/healthtopics/ undergoing thoracentesis and paracentesis. analysis of patient safety practices. Evid Rep
J Emerg Med, 30(9): 1950-4. Healthcare-associated_infections/Pages/ Chest, 143(2): 532-8. technol Assess (summ), (43):i-x, 1-668.
index.aspx Merrer J, De Jonghe B, Golliot f et al. (2001) sznajder Ji, Zveibil fR, Bitterman H et al.
Bernard RW, stahl WM (1971) subclavian
vein catheterization: a prospective study. feller-Kopman D (2007) Ultrasound-guided Complications of femoral and subclavian (1986) Central vein catheterization. failure
i. non-infectious complications. Ann surg, internal jugular access: a proposed standard- venous catheterization in critically ill patients: and complication rates by three percutaneous
173(2): 184-90. ized approach and implications for training a randomized controlled trial. JAMA, 286(6): approaches. Arch intern Med, 146(2): 259-61.
and practice. Chest, 132(1): 302-9. 700-7. van Den Bos J, Rustagi K, Gray t et al. (2011)
Bodenham AR (2011) Ultrasound-guided
subclavian vein catheterization: beyond just fraenkel DJ, Rickard C, Lipman J (2000) Can national institute for Health and Clinical the $17.1 billion problem: the annual cost
the jugular vein. Crit Care Med, 39(7): 1819-20. we achieve consensus on central venous Excellence (2002) Guidance on the use of of measurable medical errors. Health Aff,
catheter-related infections? Anaesth intensive ultrasound locating devices for placing central 30(4): 596-603.
Bowdle A (2014) vascular complications of
Care, 28(5): 475-90. venous catheters. [Accessed 24 April 2015] World Health organization (2015) Preventing
central venous catheter placement: evidence-
fragou M, Gravvanis A, Dimitriou v et al. (2011) Available from http://www.nice.org.uk/guid- bloodstream infections from central line
based methods for prevention and treatment.
Real-time ultrasound-guided subclavian vein ance/ta49/resources/guidance-guidance-on- venous catheters. [Accessed: 24 April 2015]
J Cardiothorac vasc Anesth, 28(2): 358-68.
cannulation versus the landmark method in the-use-of-ultrasound-locating-devices-for- Available from http://www.who.int/patient-
Brass P, Hellmich M, Kolodziej L et al. (2015) placing-central-venous-catheters-pdf
critical care patients: a prospective random- safety/implementation/bsi/en/
Ultrasound guidance versus anatomical land-
ized study. Crit Care Med, 39(7): 1607-12. nazeer s, Dewbre H, Miller A (2005) Ultra- World Health organization (2015) PRoHiBit
marks for internal jugular vein catheterization.
Gibbs fJ, Murphy MC (2006) Ultrasound guid- sound-assisted paracentesis performed - Prevention of hospital infections by interven-
Cochrane Database syst Rev, (1): CD011447.
ance for central venous catheter placement. by emergency physicians vs the traditional tion & training. Effectiveness of a programme
Constantino G, Parikh AK, satz WA et al. (2005) technique: a prospective, randomized study.
Hosp Physician, 42(3): 23–31. to prevent catheter-related bloodstream
Ultrasonography-guided peripheral intrave- Am J Emer Med, 23(3): 363-7.
Karakitsos D, n Labropoulos, De Groot E infections (CRBsi) in a number of European
nous access versus traditional approaches
et al. (2006) Real-time ultrasound-guided o’Grady nP, Alexander M et al. (2011) hospitals [Accessed: 24 April 2015] Avail-
in patients with difficult intravenous access.
catheterisation of the internal jugular vein: summary of recommendations: guide- able from http://www.who.int/patientsafety/
Ann Emerg Med, 46(5): 456-61.
a prospective comparison with the landmark lines for the prevention of intravascular implementation/bsi/prohibit-outcomes/en/
Crowley M, Brim C, Proehl J et al. (2012) catheter-related infections. Clin infect Dis, index2.html
technique in critical care patients. Crit Care,
Emerency nursing resource: difficult intra- 52(9): 1087–99.
10(6): R162. Zhan C, M smith, D stryer (2004) incidences,
venous access. J Emerg nurs, 38(4): 335-43.
Leidel BA, Kirchhoff C, Bogner v et al. (2009) o'Grady nP, Alexander M, Dellinger EP et outcomes and factors associated with iatro-
Defalque RJ (1974) Percutaneous catheter- al. (2002) Guidelines for the prevention of genic pneumothorax in hospitalized patients.
is the intraosseous access route fast and
ization of the internal jugular vein. Anesth intravascular catheter-related infections. Academy Health Annual Research Meeting,
efficacious compared to conventional central
Analg, 53(1): 116-21. infect Control Hosp Epidemiol, 23(12): 759-69. 6-8 June, san Diego, CA, UsA. [Abstract]
venous catheterization in adult patients under
Denys BG, Uretsky Bf (1991) Anatomical resuscitation in the emergency department? A Pronovost P, needham D, Berenholtz s et al. [Accessed: 24 April 2015] Available from
variations of internal jugular vein location: prospective observational pilot study. Patient (2006) An intervention to decrease catheter- http://www.academyhealth.org/files/2004/
impact on central venous access. Crit Care abstracts/quality.pdf

62
MATRIX
LACTATE MONITORING
Maarten W. Nijsten, MD,

PhD
Associate Professor
T he use of lactate measurements in criti-
cally ill patients has steadily increased
to a level where in some cases it may
be considered lactate monitoring. In this brief
review we discuss the central metabolic role
Although all oxygen-consuming tissues possess
the ability to consume lactate, the liver and kidneys
also possess the ability to convert this lactate
back into glucose (gluconeogenesis) and export
this glucose into the circulation. The Cori cycle
Department of Critical Care
University Medical Center Groningen of lactate in animal metabolism, and address describes the conversion of glucose to lactate by
University of Groningen important misconceptions as well as why muscles, the subsequent transport of lactate to the
The Netherlands lactate is mainly a marker of stress and how liver, regeneration of glucose by gluconeogenesis
m.w.n.nijsten@umcg.nl this translates into its unique diagnostic utility in the liver and then transport of glucose back to
in many acute conditions. Finally several inter- the muscle. This cycle is an important example of
Jan Bakker, MD, PhD esting future perspectives in lactate monitoring acute whole-body metabolic interaction between
Professor of Medicine are discussed. two organs. The Cori cycle allows muscles to
Vice-Chair, Department of Intensive
Care – Adults
Elucidation of Lactate Metabolism
Erasmus MC University Medical
Center and Misconceptions about Lactate “Even a far higher frequency
Rotterdam
The Netherlands
The history of lactate measurement and lactate of measurement of circulating
metabolism is a fascinating story (Kompanje et
Professor of Medicine
Department of Intensive Medicine
al. 2007), having important relevance for current [La-] might be informative”
Pontifical Catholic University of Chile
views on lactate, as some misunderstandings
Santiago, Chile persist. From the moment it was recognised that perform longer during strenuous exercise, since
Adjunct Professor of Medicine
lactic acid is generated when milk sours, some of the liver offloads the lactate-producing muscle.
Division of Pulmonary, Allergy, and the keenest investigators studied lactate metabo- This cycle comes at a metabolic ‘cost’, however.
Critical Care lism. Several Nobel prize winners, including Otto When glycolysis generates two ATP from a glucose
Columbia University College of Physi- Meyerhof, Otto Warburg, Hans Krebs, Carl Cori and molecule in the muscle, the liver must spend six
cians and Surgeons
New York-Presbyterian Hospital
Gerty Cori (Voet and Voet 2011) helped elucidate ATP to regenerate glucose from lactate. Thus at
New York, NY, USA lactate metabolism. Although often interchange- the whole-body level the Cori cycle entails a loss
ably used, lactic acid (HLa) and lactate (La-) are of of four ATP for each recycled glucose. In contrast
ICU Management Editorial Board
course different entities, but for brevity we will not to the Cori cycle, the direct reuse of lactate by
Member
address this topic. Even at extreme physiological the mitochondria of other cells carries no energy
conditions HLa is fully dissociated into H+ and La-. penalty (Voet and Voet 2011).
Key Messages When cells produce and export H+ and La-, the H+ A persistent misconception about lactate metab-
• Lactate is a central interme- will be partially buffered in the extracellular space. olism is that lactate production automatically
diate metabolite that is usually Early in the 20th century it was recognised that implies “anaerobic glycolysis”. However, in the
increased because of stress.
glucose is a fuel used by virtually all living organ- majority of conditions lactate production occurs
isms. In the middle of the 20th century it was in the presence of sufficient oxygen and fully
• of all laboratory parameters, discovered that in animals mitochondria are able functioning mitochondria. This is both the case
in the spectrum of critically ill to fully oxidise carbohydrate and fat to CO2 and in physiology (e.g. during maximal exercise)
patients, lactate has the stron- thereby generate far more ATP (adenosine triphos- and in pathophysiology (e.g. sepsis). A related
gest relation with outcome. phate) with so-called oxidative phosphorylation popular misconception is that muscle ache is
• the rate of change of circulating than is possible by conversion of glucose to pyru- the result of accumulation of lactic acid. Thus
lactate is also of prognostic vate (glycolysis) alone. In the complete absence lactate has long been considered a detrimental
importance. of oxygen, cells or tissues that are capable of both waste product, in particular since regeneration
glycolysis and oxidative phosphorylation can only of glucose from it by the Cori cycle involves loss
• Monitoring of lactate on short
use glycolysis. When glycolysis produces pyruvate of ATP. But lactate is far from a waste product.
timescales is both scientifically
that cannot be further metabolised by mitochon- Just like glucose, lactate is a fuel with an ATP
and clinically useful.
dria, this pyruvate must be converted into lactate yield on par with glucose upon complete oxida-
• future trials may establish in order for glycolysis to continue.This lactate must tion. Given lactate’s central metabolic role, the
whether continuous lactate then be transported out of the cell, and can then body can metabolise hundreds up to thousands
monitoring improves outcome. be converted back to pyruvate and metabolised by of millimoles of lactate per day (Cole 2003).The
mitochondria elsewhere in the body. use of the term ‘clearance’ in the case of lactate

64
MATRIX
glucose-control are combined with lactate and

blood gas analysis, resulting in many [La-]
values per day.
Theoretically even a far higher frequency of
measurement of circulating [La-] might be
informative. The known relevant biological varia-
tion of a specific signal in relation to the accu-
racy of measurement determines the minimal
timescales of scientific or clinical interest. In
the case of [La-] an interval of one minute
makes sense, since modern detectors achieve
0.1 mmol/L accuracy and [La-] can decrease
by >0.1 mmol/L/min during recovery and
increase by >1 mmol/L/min during severe
stress. The rate of recovery of hyperlactataemia
Figure 1. three Metabolic states with Respect to Lactate Production and Consumption differs per condition. A decrease of 20% per
source: Adapted from Bakker 2013 hour suggests successful sepsis treatment (Jansen
in most (patho)physiological conditions, acute energy requirements are a key driver of local or systemic lactate levels, 2010), but after cardiopulmonary resuscitation
irrespective of local oxygen tension.
or generalised seizures faster recovery rates
the left panel depicts non-stressed steady-state conditions where glucose is converted to pyruvate, which is subsequently
fully oxidised to Co2, generating approximately 36 AtP (adenosine tri-phosphate) per glucose molecule. are the rule (Vincent et al. 1983).
the mid panel depicts a stressed situation where tissue immediately requires more AtP. Glycolysis generates only 2 AtP but
can very rapidly increase by a two or three orders of magnitude. Even with optimal mitochondrial oxygenation and function,
this rate of pyruvate production will saturate the much more complex but much less flexible process of oxidative phosphory- Monitoring of Lactate and its
lation. thus for glycolysis to continue, pyruvate must be converted to lactate. Clinical Utility as a Strong Marker
the right panel depicts the post stress situation when lactate is converted back to pyruvate and fully oxidised. since lactate
can be transported both at micro and at macro scales, lactate shuttles exist that allow the simultaneous production and
of Outcome
consumption of lactate by different cells or tissues. It is now well-established that of all avail-
able laboratory measurements circulating
is not appropriate, since its concentration is the well-established univariate relation of hyper- lactate has the strongest univariate relation
net result of the rapidly varying production and glycaemia with mortality disappeared when with outcome. It is quite unlikely that another
consumption by many tissues (see Figure1). hyperlactataemia was included. The investigators routine laboratory measure will emerge that
concluded that stress is the common denominator will outperform lactate in this respect. It should
Hyperlactataemia and Stress of both hyperlactataemia and hyperglycaemia be noted that obviously no single laboratory
Although severe hypoxia or anoxia induce lactic (Kaukonen 2014). value, including lactate, should serve as the sole
acidosis, the relation cannot be used in reverse, In animal studies, treatment of healthy dogs with value to interpret the condition of a patient.
because in the majority of cases in the ICU hyper- prednisone dose dependently increased blood As transpires from its function during stress,
lactataemia is not caused by hypoxia but by stress. lactate levels (Boysen et al. 2009). Furthermore a high [La-] is not harmful by itself, but repre-
The three main conditions regarding lactate a prospective controlled trial in cardiac surgery sents a compensatory response to a variety of
production and consumption are depicted in patients (Ottens 2015) showed that the synthetic severe underlying conditions (Kraut 2014).
Figure 1. During resting steady state condi- glucocorticoid dexamethasone both induces Thus [La-] may be considered the ultimate
tions glycolysis and oxidative phosphorylation hyperglyacemia and hyperlactataemia, under- example of a biochemical marker and not a
are balanced, with no production of lactate. scoring the deep connection between both the mediator of poor outcome. The considerable
During stress, when increased ATP production adrenergic and the corticoid stress response and clinical utility (Jansen 2009) of [La-] rests
is required, glycolysis can increase manifold. subsequent elevations of both lactate and glucose. particularly on its specificity and less on its
In these conditions excessive lactate produc- sensitivity, as illustrated by the traffic light
tion is not an indicator of tissue hypoxia, but cartoon (see Figure 2).
simply reflects the ability of glycolysis to vastly
outrun mitochondrial oxidative phosphorylation
“Structured decision support A marker that highlights situations that entails
increased risk can help physicians and nurses to
(Gladden 2004). The poor relation of increased to best interpret increased focus their diagnostic and therapeutic resources
[La-] with oxygen delivery parameters underscores
that stress, not hypoxia, is the common driver
[La-] may be of use.” on those who stand to benefit most. In our
experience it is possible in most patients with
of hyperlactataemia (Bakker 1991). marked hyperlactataemia to correctly identify
It is well known that adrenergic β2-activation Timescales on which Changes in the underlying cause. When the cause is not
can directly induce production of lactate (Levy [La-] can Occur immediately evident, it may trigger appro-
2008) and glucose. In addition, a recent study In many institutions [La-] is measured on ED priate additional investigations. The prospec-
showed that hyperlactataemia and hyperglycaemia admission and upon ICU admission and thereafter tive randomised LACTATE trial was the first
are closely associated and related to mortality daily or only on indication. In other institutions to demonstrate the benefit of [La-] guidance
in a large patient cohort (Kaukonen 2014). The all glucose measurements performed for ICU during early sepsis treatment (Jansen 2010).

66
MATRIX
2014) or complete liver failure (Oldenbeuving goal for computerised lactate support should be
2014). Likewise the time course of [La-] after an to improve understanding of [La-] dynamics and
IV lactate bolus can be used to quantify the liver’s leave the specific diagnostic and therapeutic actions
metabolic ability in real time and repeatedly (Tapia to the intensivists.
et al. 2015). Lactate sensors employ technology very similar to
Eventual incorporation of [La-] into scoring glucose sensors.Thus many measurement techniques
systems that predict mortality such as APACHE developed for glucose can be ported to lactate.
or SAPS seems inevitable, since [La-] univariately Although [La-] is currently mostly determined
outperforms all known biochemical markers for in critically ill patients, this measurement may
predicting mortality. Inclusion of [La-] is long also be employed in patients on general wards or
overdue, because these scoring systems already even in outpatients. A potentially very important
Figure 2. the Practical importance of Lactate incorporate many less powerful but equally avail- example of the latter group may be type II diabetics
Monitoring
able predictors such as potassium, leukocyte count who usually use metformin. Metformin is a key
A large amount of information must be integrated (sub)
consciously by intensivists when assessing iCU patients. or glucose. oral antidiabetic drug used by maybe 100 million
some parameters serve as a generic alert that something An important conceptual challenge is to trans- patients worldwide. A small but important minority
is wrong, although it may not immediately be clear what is
wrong. An abnormally high [La-] or ∆[La-] serves as such a late the predictive power of [La-] and Δ[La-]/Δt of these patients can develop metformin associ-
warning to critically assess the condition of the patient and
consider alternative diagnoses and additional interventions.
for specific conditions to sufficient pathophysi- ated lactic acidosis (MALA). Hand-held combined
the red colour signifies the most alarming condition since ological understanding, so that an increased [La-] lactate and glucose measurements would be very
[La-] is elevated and still rising. obviously, a normal [La-]
(green sign) makes severe conditions less likely, but can can be optimally interpreted in individual cases. useful for timely detection of emerging MALA
never exclude them. Because many different acute conditions can lead in this very large population of chronic patients.
to hyperlactataemia, we believe structured decision
Future Perspectives – Decision support to best interpret increased [La-] may be Conclusion
Support of use. Building on the principles set out in the Lactate is a central intermediate metabolite that
We anticipate several developments concerning LACTATE study (Jansen 2010), we are currently allows the flexible integration of the two ATP-
lactate monitoring. Continuous lactate monitoring developing such a decision support system. Optimal generating systems that animals possess. Increases
holds great promise as suggested by first clinical interpretation of a rise in [La-] within a specific in lactate may usually reflect metabolic stress rather
studies in cardiac surgery patients with a continuous clinical context may also prevent incorrect reflexes than tissue hypoxia. Increased lactate levels have a
intravascular microdialysis system that allows ex of caregivers. Unfortunately, even in our ICUs we stronger relation to mortality than observed for
vivo detection of circulating lactate and glucose frequently discover that a fluid bolus is administered any other biochemical marker.
levels (Schierenbeck 2014). Measuring [La-] on when [La-] rises, even if hyperlactataemia does The scientific and clinical rationale for more
timescales of minutes will likely uncover important not result from hypovolaemia, but for example frequent measurements of [La-] is supported by
hitherto undetected phenomena. from anxiety (ter Avest 2011). Designing lactate a growing body of evidence and facilitated by
Continuous combined lactate and glucose moni- computer support will be inherently more complex advanced analysers. The emerging technology
toring may provide a powerful tool to monitor than computerised glucose or potassium control, of continuous lactate measurements also holds
liver function, something currently not possible. since in glucose or potassium control measurement large scientific and clinical promise for critically
When serial measurements show that [La-] rises and therapeutic corrections can to a large extent ill patients.
whilst [Glu] is ‘normal’ or decreases, gluconeogen- be fully ‘outsourced’ to the computer and the ICU We will study the impact of continuous lactate
esis may be impaired, indicating partial (de Felice nurse (Vogelzang 2008; Hoekstra 2010).The first monitoring on outcome in future trials.
References May 2015] Available from http://www.esicm2go. Crit Care Med, 42(6): 1379-85. schierenbeck f, nijsten MW, franco-Cereceda
org/libraryEntry/show/1093267020025360444 Kompanje EJ, Jansen tC, van der Hoven B et A et al. (2014) introducing intravascular micro-
Bakker J, Coffernils M, Leon M et al. (1991) dialysis for continuous lactate monitoring
Blood lactate levels are superior to oxygen- Gladden LB (2004)Lactate metabolism: a new al. (2007). the first demonstration of lactic acid
paradigm for the third millennium. J Physiol in human blood in shock by Johann Joseph in patients undergoing cardiac surgery: a
derived variables in predicting outcome in prospective observational study. Crit Care,
human septic shock. Chest, 99(4): 956-62. 558 (Pt. 1): 5-30. 5-30. scherer (1814-1869) in January 1843. intensive
Care Med 33(11): 1967-71. 18(2): R56.
Bakker J, nijsten MW, Jansen tC (2013). Hoekstra M, vogelzang M, Drost Jt et al. (2010)
implementation and evaluation of a nurse- Kraut JA, Madias nE (2014) Lactic acidosis. n tapia P, soto D, Bruhn A et al. (2015) impair-
Clinical use of lactate monitoring in criti- ment of exogenous lactate clearance in
cally ill patients. Ann intensive Care, 10(3): centered computerized potassium regulation Engl J Med, 371(24): 2309-19.
protocol in the intensive care unit--a before experimental hyperdynamic septic shock is
12. Levy B, Desebbe o, Montemont C et al.(2008) not related to total liver hypoperfusion. Crit
and after analysis. BMC Med inform Decis increased aerobic glycolysis through beta2
Boysen sR, Bozzetti M, Rose L et al. (2009) Mak, 10: 5. Care, 19(1): 188.
Effects of prednisone on blood lactate stimulation is a common mechanism involved
Jansen tC, van Bommel J, Bakker J (2009) in lactate formation during shock states. ter Avest E, Patist fM, ter Maaten JC et al
concentrations in healthy dogs. J vet intern (2011). Elevated lactate during psychogenic
Med, 23(5): 1123-5. Blood lactate monitoring in critically ill patients: shock, 30(4): 417-21.
a systematic health technology assessment. Crit hyperventilation. Emerg Med J, 28(4): 269-73.
Cole L, Bellomo R, Baldwin i et al. (2003) oldenbeuving G, McDonald JR, Goodwin ML et
Care Med, 37(10): 2827-39. al. (2014) A patient with acute liver failure and vincent JL, Dufaye P, Berré J et al. (1983)
the impact of lactate-buffered high-volume serial lactate determinations during circula-
hemofiltration on acid base balance. inten- Jansen tC, van Bommel J, schoonderbeek extreme hypoglycaemia with lactic acidosis
fJ, et al. (2010) Early lactate-guided therapy who was not in a coma: causes and conse- tory shock. Crit Care Med, 11(6): 449-51.
sive Care Med, 29(7): 1113–20.
in intensive care unit patients: a multicenter, quences of lactate-protected hypoglycaemia. voet D, voet J (2011) Biochemistry. 4th ed.
de felice E, Woittiez L, schierenbeck f et open-label, randomized controlled trial. Am J Anaesth intensive Care, 42(4): 507-11. Hoboken, nJ: John Wiley & sons.
al. (2014) Early lactate and glucose levels Respir Crit Care Med, 15, 182(6): 752-61. ottens tH, nijsten MW, Hofland J et al. (2015) vogelzang M, Loef BG, Regtien JG et al.
and subsequent liver failure and mortality Kaukonen KM, Bailey M, Egi M et al (2014). Effect of high-dose dexamethasone on peri- (2008) Computer-assisted glucose control
in critically ill patients. European society of stress hyperlactatemia modifies the rela- operative lactate levels and glucose control: a in critically ill patients. intensive Care Med,
intensive Care Medicine, 27 september-1 tionship between stress hyperglycemia and randomized controlled trial. Crit Care, 19(1): 34(8): 1421-7.
october, Barcelona. [Abstract] [Accessed: 6 outcome: a retrospective observational study. 41.

bOOTh 83a
Visit us at
EuroaNaESThESIa,
68
MATRIX
EARLY SEPSIS MANAGEMENT

Sepsis is a recognised clinical spectrum of infection that often results in catastrophic physiologic and
metabolic abnormalities. This article aims to identify the derangements associated with sepsis and to
review the evidence-based literature.
sepsis. We will discuss these treatments in the Source Control

paragraphs to follow. Source control is imperative and should be
The incidence of sepsis is rising as patients done as quickly as possible following initial
Jacqueline who are at high risk are living longer with resuscitation. The tenets of source control are
Pflaum-Carlson, MD multiple co-morbidities. As a result hospitalisa- appropriate radiographic imaging and inter-
Department of Emergency Medicine tion for the diagnosis of sepsis is increasingly pretation, removal of the insult or a defini-
Department of Internal Medicine
more common. Sepsis-associated mortality tive surgical procedure. Every hour of delay
Pulmonary and Critical Care Medicine
Henry Ford Hospital ranges from 15-49% (Angus et al. 2001), and from admission to surgery has been associated
Wayne State University contributes to nearly 17-40% of hospital deaths, with an adjusted 2.4% decreased probability
Detroit, Michigan, USA making it the most lethal hospital admission of survival or a 16% reduction in mortality
diagnosis (Kumar et al. 2011). As the popula- if no source control within 6 hours (Bloos et
Jayna Gardner-Gray, MD
tion continues to age, sepsis-related admissions al. 2014; Marshall and al Naqbi 2009; Buck
Department of Emergency Medicine

Department of Internal Medicine are projected to continue to rise, making stan- et al. 2013). Patients who had surgical source
Pulmonary and Critical Care Medicine dardised approaches to the identification and control delayed for more than 6 hours had a
Henry Ford Hospital treatment of sepsis imperative. significantly higher 28-day mortality (42.9%
Wayne State University
Detroit, Michigan, USA
vs. 26.7%, p < 0.001); this delay was inde-
Early Detection or Screening for pendently associated with an increased risk
Gina Hurst, MD
Sepsis of death (Bloos et al. 2014; Dellinger et al.
Department of Emergency Medicine The systemic inflammatory response syndrome 2013b).
Department of Internal Medicine, (SIRS) was developed as a clinical aid to
Pulmonary and Critical Care Medicine direct the clinician to entertain the diag- Risk Stratification (Lactate and
Henry Ford Hospital
Wayne State University
nosis of infection. It comprises two of the Refractory Hypotension)
Detroit, Michigan, USA following four items: 1) temperature >38.3°C A hypotensive episode (systolic blood pres-
or <36.0°C; 2) heart rate >90 beats/min; 3) sure less than 90 mmHg) is associated with
Emanuel P Rivers, MD, respiration rate >20 breaths/min or 4) white an increased risk for death whether in the ED
MPH blood cell count >12,000 or <4000/mm3 , or inpatient unit (Jones et al. 2006; Lee et al.
Department of Emergency Medicine
Department of Surgery or >10% increased bands or immature cells 2014). The discriminatory value of hypoten-
Henry Ford Hospital (Bone 1985; Rangel-Frausto et al. 1995). The sion increases after a fluid challenge (Lee et
Wayne State University first use of SIRS for screening revealed that al. 2014). If hypotension is not corrected by
Detroit, Michigan, USA
the more SIRS criteria, the greater degree of a fluid challenge, this portends early organ
admission, increased length of hospital stay dysfunction, haemodynamic decompensation
and costs (Tuttle 1996). and increased mortality (Lee et al. 2014; Liu
et al. 2013; Khalid et al. 2014). Ironically,
Antibiotic Therapy paradoxical hypotension can be seen after fluid
The evidence for cultures and early and appro- challenge (Lee et al. 2014b). Hypotensive ward
T he tenets of early sepsis management

include diagnosis, risk stratification
(elevated serum lactate or hypotension),
assessment of haemodynamic response after
a fluid challenge, antibiotics, source control
priate antibiotic administration is abundantly
present in both animal and human studies of
sepsis (Natanson et al. 1990). Bacteraemia is
associated with an increased mortality, and this
mortality may be increased up to five-fold in
patients who deteriorate further after initial
stabilisation have a higher mortality (up to
42%, 28-day) and increased hospital resource
consumption (Champunot et al. 2014; Khalid
et al. 2014; McKinley et al. 2011). Hypotension
and haemodynamic optimisation. Whether this patients who receive inappropriate initial anti- refractory to fluids and requiring vasopressor
combination of interventions is called early biotic therapy (Kang et al. 2012; Cardoso et therapy carries a mortality of 20 to 52% (Levy
goal-directed therapy (EGDT), the resuscitation al. 2010; Levy et al. 2010; Kumar et al. 2009). et al. 2010; Cannon et al. 2010; Durairaj and
bundle (RB) or a standard operating procedure Mortality can increase up to 7.6% for each hour Schmidt 2008; Hilton and Bellomo 2012; Lee
(SOP), mortality is improved when performed. delay in antibiotic administration after the onset et al. 2012).
Figure 1 (EGDT algorithm) on p.70 delineates of hypotension or shock (Kumar et al. 2006; Weil and Aduen et al. established the prog-
how to carry out EGDT in the management of Ferrer et al. 2014). nostic value of a lactate greater than or equal

to 4mM/L on hospital admission, which has been confirmed by
multiple studies (Broder and Weil 1964; Cady et al. 1973; Aduen et
al. 1994; Mikkelsen et al. 2009; Trzeciak et al. 2007; Shapiro et al.
2005; Pearse 2009). Whether central venous or arterial (Reminiac et
al. 2012), increased lactate levels are associated with increased mortality
(Puskarich et al. 2014; Howell et al. 2007). Clinical deterioration in patients
with intermediate lactate levels (between 2.0 and 4.0 mmol/L) means that
they are particularly at risk for mortality, as 22.7% will progress to sepsis-
induced tissue hypoperfusion with an associated mortality of 10.1% (Hoon
et al. 2012).
Lactate levels can be normal in septic shock and should be used with caution
as a sole screening tool and endpoint (Singer et al. 2014; Dugas et al. 2012;
Wacharasint et al. 2012; Cannon et al. 2013; Song et al. 2012). Blood lactate
levels are not uniformly elevated in critically ill patients with liver disease, and
levels above 2.2 mM/L are associated with increased mortality (Kruse et al.
1987). A normal shock index (heart rate/systolic blood pressure (<0.7) in
patients presenting with a presumed infection indicates very low risk (high
negative predictive value) for increased lactate levels (>4 mM/L) (Berger et
al. 2013; Rady et al. 1994; Rady et al. 1996).
The Pathobiology of Haemodynamic Optimisation

Sepsis is a result of severe haemodynamic triggers that ultimately result in

an imbalance between oxygen supply and demand. Based on this principle,
EGDT sought to identify these abnormalities and aim for early correction
and restoration of homeostasis. In light of a trilogy of recent publications
comprising Protocolized Care for Early Septic Shock (ProCESS) (ProCESS
Investigators et al. 2014), Australasian Resuscitation in Sepsis Evaluation
(ARISE) (ARISE Investigators et al. 2014) and Protocolized Management in
Sepsis (ProMISe) trials (Mouncey et al. 2015), this article aims to highlight
the best practice recommendations for early sepsis management.
Preload Optimisation or Intravenous Fluids

Due to physiologic fluid shifts and fluid losses, septic patients are often
volume depleted, and a minimum of 20-30ml/kg of fluid should be given.
Following this initial bolus, infusion of intravenous fluids may be continued
as long as the patient continues to improve haemodynamically. In regards to
choice of fluid therapy, studies have shown that resuscitation with crystal-
loids, such as normal saline or lactated Ringer’s or albumin, does not confer
a reduced mortality in severe sepsis but may in septic shock (Rochwerg et al.
2014; Delaney et al. 2011). Albumin may be a considerable adjunct when
patients require large amounts of crystalloid infusion (Caironi et al. 2014).
One of the benefits of aggressive fluid therapy is a reduction in vasopressor
use during the first 6 hours. Early reduction in vasopressor therapy further
reduces the need for vasopressin and corticosteroid use and may confer
improved mortality (Waechter et al. 2014).
Preload Measurement (Central Venous Pressure or Other

Surrogates)
A central venous pressure (CVP) of between eight and 12 mmHg is recom-
mended to mitigate the circulatory insufficiency in the form of hypovolaemia
and loss of vasomotor tone. Recent studies have called into question the value
and necessity of CVP monitoring, due to inability to find a reliable relation-
ship between blood volume and recorded CVP (Schmidt 2010; Marik and
Cavallazzi 2013). Clinically the picture is often more complex than an isolated
number, as coexisting conditions such as anaemia, myocardial suppression,
mechanical ventilation, arrhythmias and vasopressor administration can
70
MATRIX
Thus the focus during the first hour should be

aggressive fluid administration, only thereafter
starting vasoactive agents, while continuing aggres-
sive fluid administration (Waechter et al. 2014).
Central Venous Oxygenation

Central venous oxygenation (ScvO2) has the unique
ability to demonstrate imbalances between oxygen
delivery and oxygen consumption, and studies have
repeatedly proven the utility and outcome benefit
of this endpoint (Chamberlain et al. 2011). For
instance, it has been shown that early ScvO2 can
predict the difference between sepsis survivors and
non-survivors and outcomes in acute lung injury
after nearly 47 hours (Varpula et al. 2005). EGDT
calls for action manoeuvres based on persistently
low ScvO2 on the basis that therapies are neces-
sary to either increase oxygen delivery or decrease
venous oxygen consumption to prevent or limit tissue
hypoxia, lactate generation and cardiopulmonary
complications. Suggested goals for increasing ScvO2
involve fluid resuscitation, inotropic administration,

red blood cell transfusion and decreasing systemic
oxygen demands (early intubation). Although the
trilogy of recent sepsis trials confer no mortality
benefit of ScvO2 over usual care, recent studies show
Figure 1. Algorithm of Early Goal-Directed therapy with Recommended Ancillary treatments increased mortality and outcome benefits when ScvO2
is corrected (Boulain 2014; Levy et al. 2014).
play a role in falsely elevated or depressed values. cardiac output, improved microvascular function
CVP-guided fluid administration has been shown and decreased blood lactate concentrations, there is Arterial Oxygen Content (Oxygen and
to decrease vasopressor therapy and in the early substantial individual variation (Thooft et al. 2011). Blood Transfusion)
stages of sepsis has been shown to decrease mortality An individual's physiologic baseline and personal Anaemia in sepsis is associated with an increase in
(Walkey 2013). On the contrary, aggressive fluid needs should be contemplated on a case-by-case both myocardial and systemic oxygen extraction
resuscitation in the late stages of the sepsis spectrum basis; however, the recommended target mean arterial rates accompanied by a compensatory increase in
has been shown to increase morbidity, mortality and blood pressure is 65 mmHg (Varpula et al. 2005; cardiac output. Anaemia can be multifactorial, and
ventilator-dependent days (Murphy et al. 2009). In Dunser et al. 2009; Asfar et al. 2014). Levy et al. the underlying causation ranges from the dilutional
patients in whom central line placement is difficult have shown that the delayed use of vasopressor effect of aggressive fluid resuscitation, bone marrow
or undesirable, bedside echocardiography, inferior therapy for cardiovascular support is incrementally suppression, disseminated intravascular coagulation
vena cava measurements for respiratory variation, associated with a significantly higher mortality than and the presence of pre-existing illness. Ultimately,
transoesophageal Doppler monitoring and stroke any other organ failure beyond the first 24 hours the increase in myocardial oxygen consumption
volume variation using arterial pulsation monitoring (Levy et al. 2005). can lead to troponin elevations, increasing lactate
can be alternatives. However, clinical pitfalls exist There has been no demonstrable difference in levels, tachyarrhythmias and persistent hypotension.
with these modalities as well, and the clinical picture the rate of death between patients treated with Targeting a pre-established ‘optimal number’ can
on the whole should be given greater weight than dopamine as the first-line vasopressor agent or be complicated as haemoglobin concentrations
an isolated lab or mechanical value. norepinephrine; however, the use of dopamine and requirements vary by organ, circulation and
has been associated with a greater number of adverse co-morbidities. Prior transfusion-related studies
Afterload (Blood Pressure Target and events (De Backer et al. 2010). Although studies have shown inconsistent data, with a recent study
Vasopressor Use) have not shown outcome improvements with low- showing no significant difference in 90-day mortality,
Sepsis-associated vasodilatation and the loss of dose vasopressin, there is evidence that concomitant use of life support or ventilator-free days when a
systemic autoregulation often necessitate admin- corticosteroid therapy may be beneficial (Russell level of seven g/dL versus nine g/dL was targeted
istration of vasopressors (Dellinger et al. 2013a). et al. 2009; Gordon et al. 2014). (Holst et al. 2014). Current recommendations aim
Studies have shown that delays in restoration of Initiation of vasopressor therapy should be done to limit transfusions to patients with persistently
physiologic blood pressure are related to increased with caution, as it may be detrimental. Early initia- low ScvO2 despite appropriate interventions based
mortality risk (Dunser et al. 2009; Beck et al. 2014). tion can falsely elevate CVP if started immediately on the patient’s clinical picture, including vital
While increasing mean arterial pressure (MAP) after central venous line placement and prior to signs and known pre-existing conditions (cardio-
above 65 mmHg has been associated with increased complete fluid resuscitation (Nouira et al. 2005). vascular disease).

71
MATRIX
ProMISe
ProCESS ARISE (Mounc-
Myocardial Dysfunction EGDT (ProCESS Investiga- (ARISE Investiga- ey et al.
Suspicion of myocardial dysfunction should be raised in patients (Rivers et al. 2001) tors et al. 2014) tors et al. 2014) 2015)
with persistently low ScvO2, elevated CVP and lactate level. Multi-centre,
This can be present in up to 15% of patients of patients in Location United States United States multinational England
septic shock (Jozwiak et al. 2011). Bedside ultrasound may Average number of Patients
demonstrate depressed ejection fraction and decreased cardiac enrolled per month/centre 7 0.7 0.5 31.5
motility. Dobutamine is the first-line inotropic therapy due Lactate screening None Required Required Required
to its ability to increase cardiac output by increasing cardiac Existing sepsis protocols Yes, (SSC and indi-
contractility and heart rate. While its use in sepsis has not (SSC 2004, 2008, and 2012) No vidual centres) Yes
been shown to improve mortality, a trial of dobutamine up to (SSC and national standards) No
20μg/kg/min carries a 1C recommendation by the Surviving
Care provided (blinded) ED unblinded
Sepsis Campaign guidelines.
ICU was blinded ED/ICU unblinded ED/ICU unblinded ED/ICU unblinded
Decreasing Systemic Oxygen Demands
Increased metabolic demands, which cannot be met by increasing Table 1. study Comparison
systemic oxygen delivery, can contribute to ongoing tissue ARisE, Australasian Resuscitation in sepsis Evaluation; ED, emergency department; EGDt, early goal-directed therapy; iCU, intensive
hypoxia. Fever and increased work of breathing can account for care unit; ProCEss, Protocolized Care for Early septic shock; ssC, surviving sepsis Campaign
up to 40% of oxygen consumption in sepsis and animal studies

EGDT ARISE ARISE ProMISe
have shown mechanical ventilation to mitigate the early effects
of sepsis on haemodynamics (Correa et al. 2012; Manthous et EGDT Control EGDT PBST UC EGDT UC EGDT UC
al. 1995; Beisel 1980). Initial mechanical ventilation should Fluids prior
2,254 2,226 2,083

be approached with caution as it can decrease venous return, ENR, mL
and the medications used for rapid sequence intubation are Total fluids
associated with blunting of the sympathetic drive and arterial 0-72 hours 7,720 8,175 6,663 6,906 6,672 5,153 5,194
mL
and venous dilation. If aggressive fluid resuscitation has yet to
be undertaken, the patient can become rapidly hypotensive VP at enrol-
19.1 16.8 15.1 21
ment, %
following intubation. When these precautions are considered
VP 0-72
and mitigated, early paralysis in patients with acute lung injury 36.8 51.3 27.3 24.0 22.4 681 608
hours, %
has been associated with improved outcomes.
Any inotrope,
15.4 9.2 9.3 2.5 2.9 220 63
%
Conclusion
PRBC 0-6
A recent trilogy of studies (PROCESS, ARISE and ProMISe) 64.1 18.5 14.4 8.3 7.5 13.6 7.0 55 24
hours, %
sought to examine EGDT as a haemodynamic optimisation
Any PRBC, % 68.4 44.5 9.3 2.5 2.9 131 74
study, particularly the need for CVP and ScvO2 monitoring
during resuscitation (see Tables 1-3).These studies provided Table 2. interventions
early diagnosis, risk stratification (elevated serum lactate or ARisE, Australasian Resuscitation in sepsis Evaluation; EGDt, early goal-directed therapy; PBst, Protocol-Based standard
hypotension), assessment of haemodynamic response after therapy; PRBC, Packed Red Blood Cell; ProCEss, Protocolized Care for Early septic shock; UC, Usual Care; vP, vasopressor
a fluid challenge, antibiotics, source control and early ICU

EGDT ProCESS ARISE ProMISe
admission to all groups with unblinded care in all treatment
groups.This trilogy found no difference between EGDT and EGDT Control EGDT PBST UC EGDT UC EGDT UC
usual care as provided in these trials. Because of providing Predicted
many components of EGDT in all treatment groups, mortality mortality based
40.3 36.9 38.2 37.5 37.9 21.0 21.0 32.2 29.1
on APACHE
from sepsis has been reported at all time lows by all of these II, %
trials.The question remains whether an invasive or noninvasive
Observed
method (with or without CVP) confers improved mortality. It hospital 30.5 46.4 21.0 18.2 18.9 14.5 15.7 25.6 24.6
must be remembered that EGDT provided no harm consistent mortality, %
with proven benefit in over 45 publications comprising over 60-day
44.3 56.9 21.0 18.2 18.9
40,000 patients with equal mortality benefit as the original mortality, %
trial (Wira 2014; Jones 2008; Barochia 2010; Wang 2012; Gu 90-day
31.9 30.8 33.7 18.6 18.8 29.5 29.2
2014). While these controversies continue to be discussed, we mortality, %
do know that patients with sepsis need early intervention and Duration
benefit from parameters to measure response to resuscitation. hospital stay, 13.2 13.0 11.1 12.3 11.3 8.2 8.5 9 9
days
For full references, please email editorial@icu- Table 3. outcomes
management.org, visit www.icu-management.org or
use the article QR code. APACHE ii, Acute Physiology and Chronic Health Evaluation ii; ARisE, Australasian Resuscitation in sepsis Evaluation; EGDt,
early goal-directed therapy; PBst, Protocol-Based standard therapy; ProCEss, Protocolized Care for Early septic shock; UC,
Usual Care

72
POINT-OF-VIEW
RAPID PATHOGEN TESTING WITH

PCR/ESI-MS
The RADICAL multicentre observational study was performed to compare
PCR/ESI-MS to standard microbiology in critically ill patients.
Dr. David Brealey, Consultant Intensivist at Univer- others, in the critical care environment only on the confidence that probably there is no
sity College Hospital, London, was one of the investigators about 10% of blood cultures ever show a bacteria, fungus or virus there. That doesn’t mean
in the UK arm of this trial, and explains more about the
positive result. Assuming that most doctors there is no infection in the body, because you
challenges of diagnosing infections in the ICU and the
potential of rapid pathogen testing PCR/ESI-MS. take a blood culture because they think the can have a localized infection that doesn’t go
patient might just be septic, only 10% come into the bloodstream. It may not give you the
back as positive, and it takes about 48 hours confidence to stop antibiotics, but it certainly
What are the key challenges in the diagnosis for the results. 48 hours to wait for a result could lend some weight in that direction. We
of severe infections and sepsis? for someone who might actually be septic also looked at cultures from the respiratory tract,
The clinical definition of sepsis is extremely is just too long. We need to have antibiotics bronchoalveaoli, which are difficult to look at,
vague, and many conditions can masquerade administered within the hour. If you compare as they are colonized with a lot of different
as “sepsis”. Doctors are often unable to deter- sepsis as a medical emergency to stroke, the bacteria, and PCR/ESI-MS outperformed culture
mine when a patient’s current temperature or diagnostic process is lacking. If someone comes there and in a fraction of the time.
condition is related to an infection or some into hospital anywhere in Europe with a stroke, It was an observational trial, so we were just
other process. They worry that they may miss they will be rushed to a stroke centre, have looking at what the results were, we were not
an infection or a septic episode, and therefore a CT scan, and an immediate diagnosis and acting on them, and the clinicians didn’t know
treat the patients with antibiotics. What is treatment will be given. What they won’t the PCR/ESI-MS results. The trial didn’t answer
unclear with the current definition of sepsis do is give you a very dangerous treatment what would change if the results were known,
is how many of those patients treated with now, not really knowing whether or not you so we asked a pool of independent doctors to
antibiotics do not actually have an infection, let have the condition. Diagnostics for sepsis look at the results and the clinical case reports,
alone sepsis. The pressure on clinicians is not is far behind diagnostics for other medical and asked if they would change the way they
to miss sepsis and to prescribe antibiotics in emergencies. managed the patient. 42% stated that they would
what is described as a “timely manner”. There have altered the patient’s management. If the
are many patients getting antibiotics, who You were part of the RADICAL Study, can PCR/ESI-MS result was positive, that went up
perhaps don’t need them. That exposes them you briefly tell us about the main findings? to about 53%. Mostly they would have reduced
to a degree of risk, and in the hospital envi- The RADICAL study was a comparison of the the number of antibiotics, and leading on from
ronment the more powerful broad-spectrum rapid pathogen detection technology, PCR/ that, the side effects and the exposure and
antibiotics can have a significant impact on ESI-MS, versus standard hospital i.e. culture pressure of multi-drug resistance, resulting in
vital organ function. From the society point techniques. The study compared this in a real the de-escalation of antibiotics in the hospital
of view the broad-spectrum antibiotics drive world environment. If you were in a RADICAL environment. The question of what would
multi-drug-resistant bacteria. The issue, put centre, and the doctor was taking a blood really happen if the clinician had the result
simply, is overuse of antibiotics by doctors, culture or a culture from any other part of is unanswered at the moment, and trials are
who are unsure whether the patient is truly your body because they thought you were being designed to discover that.
infected or septic, because sepsis definitions septic, they would also take a sample for
are so poor and diagnostic techniques are PCR/ESI-MS. The two were directly compared. In which way do you think PCR/ESI-MS could
inadequate. The key finding is that PCR-ESI-MS was able improve antibiotic stewardship in the ICU?
to identify over three times the number of The technology on its own in a lab won’t make
Are the current methods used for the diag- pathogens in blood compared to culture, and a difference. But combined with active reporting
nosis of sepsis adequate? If not, why not? in about 8 hours compared to 48 hours. The hit and active stewardship it could make a massive
Currently the diagnosis of sepsis is clinical, and rate for cultures was about 11%. Eleven percent difference. The patient comes into the ED, and
it is backed up by blood or sputum cultures. of cultures found something, whereas PCR/ you think they have pneumonia – within 6-8
If you treat bacterial cultures inappropriately, ESI-MS found about 33%. The other startling hours, with PCR/ESI-MS you would know
those bacteria are not going to thrive and finding was the negative predictive value, if they have bacteria in their bloodstream. I
divide and we are not going to detect them. such that if PCR/ESI-MS was unable to find would suggest what’s needed is that as the
Giving patients antibiotics before the cultures something in 8 hours, you could be 97 percent result comes out so a microbiologist phones
are taken really lowers your chance of getting sure that your cultures were also going to to advise on what antibiotics are needed. In
any results through. At our institution and be negative at 72 hours. This gives you early hospitals it’s usually the residents who prescribe

73
POINT-OF-VIEW
antibiotics and they won’t necessarily have the be weaned off antibiotics as a crutch for any this point they are saturated in antibiotics, and
confidence to de-escalate antibiotics. So the unknown fever. We need the diagnostics to be you are unable to tell if the kidney or liver failure
speedy result need to be backed up with good sure that stopping antibiotics, or not starting is the result of drug reactions or the bone marrow
stewardship and excellent communication. them in the first place is the right thing to do. transplant or an infection or something else. Cultures
The RADICAL study is a good start. We have will all be negative because the patient is saturated
What in your opinion will be the main to get that culture change going. in antibiotics. Knowing what we are dealing with
barriers for adoption of PCR/ESI-MS? will mean cutting antibiotics out and targeting the
The main barrier to hospital administrators Can you describe for us a clinical situation ones we need to.
will be cost, and obviously the business case where you think PCR-ESI-MS could be useful? PCR/ESI-MS could make a difference when it is an
has to be made alongside the evidence for its UCL has patients undergoing bone marrow emergency and inappropriate to wait 48 hours for
effectiveness. If you can prove that this tech- transplants for haematological malignancies a result. It could revolutionize the way we handle
nology makes a difference, reduces mortality, such as leukaemia. The problem is that they sepsis, in a way we haven’t seen for decades.
time on intensive care or hospital length of are immuno-suppressed. They almost invari-
stay, antibiotic usage and therefore the drugs ably get a temperature after transplants, and Note
budget, that is the financial business case. The because we cannot diagnose it immediately, The technology (PCR/ESI-MS) evaluated in the
evidence for this needs to be amassed. they all get antibiotics. Some get better, but RADICAL study is now commercially available as
The other barrier is culture. Doctors need to some persist and come to intensive care. By the CE-marked IRIDICA platform and assays.
Reference Disclosure:
“Point-of-View” articles are part
Brealey D, Libert n, Pugin J, o'Dwyer M, Zacharowski K, Mikaszewska-sokolewicz M, Maureau MP, Ecker DJ, sampath R, singer
M, vincent JL. RADiCAL study: rapid diagnosis of suspected bloodstream infections from direct blood testing using PCR/Esi-Ms. of the ICU Management Corporate
Crit Care 2014;18(suppl 2):P61. Engagement Programme
IRIDICA
74
MATRIX
WHY IS DRUG TRACEABILITY

IMPORTANT IN A HOSPITAL?
IMPLEMENTATION AT HOSPITAL ALEMÁN IN ARGENTINA
The acute condition of hospital patients and the use of higher risk medication increases the
consequences that counterfeit and illegitimate pharmaceutical products can have on them.
Delivering the right and genuine product to the right patient is crucial.
group of pharmaceutical products. This new than 700 doctors providing care in all special-
regulation implements effective countermea- ties. The hospital has 240 beds in individual
sures against counterfeit and substandard drugs. rooms, 11 operating theatres, a coronary unit,
Heidi Wimmers, MSc Traceability is the ability to track specified adult and paediatric intensive care units, burn
Chief of Pharmacy stages of the supply chain and trace backwards area care and a transplant centre.
President, Independent Ethics Com-
mittee in Clinical Trials
the history, application or location of the phar- The barcode of the secondary packaging
Hospital Alemán maceutical products that are under consider- is just the beginning of the procedure in
Buenos Aires, Argentina ation. The global standardised identification our hospital. During the traceability process
hwimmers@hospitalaleman.com system from manufacturer to patient provides the hospital pharmacy needed to ensure that
www.hospitalaleman.com a safer healthcare supply chain. The data within they could accept and store the medicines
the GS1 (www.gs1.org) barcodes now enables in line with GS1 Standards (www.gs1.org/
automatic identification of the products at any healthcare/standards).
point in the supply chain. The end-to-end point-of-dispensing coding
I n our globalised economy, the risks of

harming the patient can stem from coun-
terfeited medicines. It is not easy to know
the counterfeit drug rate globally, because there
is significant variation across countries, but it
This secure system will identify products with
the GS1 Standards using data carriers like Data
Matrix, RFID or barcoding systems with the
“traditional” linear barcode data carriers.
The traceability process is for the pharmaceu-
involves three specific steps in our hospital:
1. Hospital reception of traceable drugs;
2. Single dose fractioning at the inpa-
tient pharmacy with the GTIN (static
data) and the dynamic data of the
affects both developed and developing countries. tical industry also a way to an eventual effective drug in each unit dose;
The higher rates are in developing countries, and fast product recall of specific batches or 3. Administration to the patient after
and drugs that treat serious diseases such as lots of medicines from the market. These could nurses have scanned the barcode
malaria, tuberculosis, AIDS or other infections be achieved in a relatively short time to avoid symbol.
are more often the object of counterfeiting. medication errors. Traceability gives also the All our suppliers were audited as a part
The most common factors leading to the possibility of a quick inventory. It is a challenge of a quality assurance programme, which
occurrence of counterfeit drugs are the lack to analyse all the supply chain inefficiencies. ensures that products are produced and
of legislation, weak national drug regulatory controlled according to the quality stan-
authorities, erratic supply of drugs, lack of Traceability Implementation at dards appropriate to their intended use and as
control of drugs for export and import, free Hospital Alemán required by the marketing authorisation and
trade zones, corruption and conflict of interest It is important that the external packaging product license (Good Manufacturing Practices).
(World Health Organization 1999). of pharmaceutical products undergoes The suppliers must provide the barcode of
Counterfeit drugs have rarely been efficacious, further control and security, thinking of the secondary packaging as a proper iden-
and in most cases they have been dangerous the global pharmaceutical supply chains. tification of their pharmaceutical products
(Amon 2008; Kelisides et al. 2007; Tomić et al. This identification of each packaging of in accordance with the national regulations.
2010). The right compounding of medicines medicines such as the Global Trade Item At the hospital reception the internal digi-
and supervision of the supply chain is a must. Number or GTIN and some dynamic and tising of the supply chain with increased
We must ensure the availability of a safe and variable data like unique serial number, efficiency begins. Each item of packaging is
efficacious drugs supply. batch/lot number and expiry date makes checked against a database and the informa-
each packaging unique. This identification tion is sent to a division of our Health Ministry,
Benefits of Traceability is now our regulatory and legal requirement the ANMAT, ensuring that the patient received
As of 1 June 2012 new regulations on the in Argentina. a genuine drug. The ANMAT exercises duties
traceability of medicines in Argentina require Hospital Alemán is a university hospital in inspection, oversight and control over food,
a specific identification to be placed on a large located in Buenos Aires, Argentina, with more medications, and medical devices in Argentina.

75
MATRIX
They manage the National Traceability System task personnel were trained, focused towards a Conclusion
for Pharmaceutical Products to the GS1 Standard. continued improvement. To continue improving the traceability process
The scan reveals if there is any duplication of The doctors in our hospital prescribe in in the hospital it is essential:
data on the packaging. In this case, the ANMAT the electronic medical history. The pharmacy • To train the personnel constantly,
System sends the pharmacy an immediate alert dispenses the medication and the nurse scans the keeping a great collaboration between
about the possibility of a fake medicine. unit dose of the original packs before admin- all members of the multitask team.
Before dispensing to a patient in the inpa- istration to the patient happens. This is one of • To focus towards continuous improve-
tient ward, the traceable drug is fractioned in the critical stages of the medical treatment. Scan- ment, in order to create confidence in
unit doses at the pharmacy. This is a huge task. ning allows confirmation that the right product the patients, personnel and management
A significant amount of time and effort has is supplied to the right patient with an online that the drug administered fulfills the
been spent to ensure full compliance with GS1 verification of batch and expiry date. The infor- specified quality requirements.
Standards. The medicines are re-labelled using mation is stored in the database of ANMAT and There is growing concern regarding coun-
a printed GS1-Data Matrix linking to the original the dispensing of each unit to a patient can be terfeit medications. Drug quality is currently
information from the pharmaceutical packs. recorded in our electronic system. receiving renewed global attention. The appear-
We re-packaged the unit doses in an aseptic The patient data remains confidential (except ance of counterfeit pharmaceutical products in
laboratory. A programme of maintenance is to the hospital pharmacist) during the entire supply chains is an international public health
implemented in order to control the machine, process. problem that may seriously affect the security
the printers and the labels. All this work is of patients. According to the World Health
carried out under the close surveillance of a Organization (WHO) definition, counterfeit
pharmacist (Cina et al. 2006; American Society “A traceability system drugs may be generic or innovative. They do
of Health-System Pharmacists 2011). not meet quality standards and do not declare
increases the protection of their real composition and/or source for the
How it Works in the Inpatient Ward
The main objective is to achieve the five well-
patients” purposes of fraud. They may contain genuine
constituents in a fake packaging, or wrong
known rights: ingredients, or inactive ingredients or an incor-
• Right patient, Outpatients rect quantity of the active substance.
• Right drug, Whenever a patient comes to our official phar- The execution of a traceability system
• Right route, macy, the pharmacist will scan the GS1 Data increases the protection of patients from falsi-
• Right time, and Matrix at the point of dispensing, and scan the fied, expired or recalled medicine. This system
• Right dose. GS1 Data Matrix on the medicine's packaging. It generates an environment of greater safety and
Providing safe healthcare depends on highly is much easier because the patient receives the allows medicine confidence for the patients,
trained individuals with responsibilities, who complete and original pack of his medicine and the medical professionals and the management
are acting together in the best interests of we only have to scan the original Data Matrix on of the Hospital Alemán. Consequently it is to be
the patient. the secondary medicines packaging. We link the hoped that criminal activities derived from the
Standardising internal processes was essential. prescribed patient’s medicine to the dispensed trade of illegal medications will dramatically
The Traceability Manual was drafted. All multi- medicine. drop in the future.
References Amon JJ (2008) Dangerous medicines: Kelisides T, Kelesidis I, Rafailidis PI et al. chain. Arh Hig Rada Toksikol, 61(1): 69-75.
unproven AIDS cures and counterfeit anti- (2007) Counterfeit or substandard antimicrobial World Health Organization (1999) Guide-
American Society of Health-System Pharma-
retroviral drugs. Global Health, 4: 5. drugs: a review of the scientific evidence lines for the development of measures to
cists (2011) ASHP statement on bar-code
Cina J, Fanikos J, Mitton P et al. (2006) J Antimicrob Chemother, 60 (2): 214-36. combat counterfeit medicines. WHO/ EDM/
verification during inventory, preparation, and
dispensing of medications. Am J Health Syst Medication errors in a pharmacy-based bar- Tomić S, Milcić N, Sokolić M et al. , et al. QSM/99.1 [Accessed: 30 March 2015] Avail-
Pharm, 68(5): 442-5. code-repackaging center. Am J Health Syst (2010) Identification of counterfeit medicines able from http://whqlibdoc.who.int/hq/1999/
Pharm 2006, 63(2): 165-8. for erectile dysfunction from an illegal supply WHO_EDM_QSM_99.1.pdf

76
MANAGEMENT
MOVING FROM “LEARNING

BY DOING” TO SIMULATION
THE EDUCATIONAL CHALLENGE IN ANAESTHESIA AND INTENSIVE CARE
reality. Poor communication has been identified a mannequin-based simulator to systematically

as the primary root cause in more than 70% of tackle such challenges during anaesthesia crisis
perinatal sentinel events recorded by the Joint situations (Gaba et al. 2001). This group, led by
Commission on Accreditation of Health Care David Gaba, developed the concept of anaes-
Organizations (2004) that suggested simulation thesia crisis resource management (ACRM),
Alessandro Barelli, MD training as an effective way to improve teamwork which addressed human factors in the oper-
Director
Simulation and Patient Safety as one of the means to improve patient safety ating room setting (Gaba et al. 2001). Since
Center (Kohn et al. 2000). Stress, poor communica- then, several centres around the world have
Teaching Hospital “A. Gemelli” tion, failure to identify and correct errors, and implemented simulation-based crisis resource
Rome, Italy
the culture of blame, often lead to undesired management training. As the concept extended
a.barelli@tox.it
outcomes in patients’ care. into different domains and specialties, it was
Evidence is increasing that traditional approaches called crew resource management (CRM)
to anaesthesia and intensive care training are (Reader et al. 2006).

no longer acceptable in the current ethical and Communication, teamwork, decision making
professional context. and situation awareness, in addition to medical
Alternatives to “learning by doing” in a clinical knowledge and practical skills, have been well
context are currently available from recent devel- defined in medical literature as categories of
Roberta Barelli, MD opments in simulation and virtual reality. competencies that are necessary for a team to
Resident, Anaesthesia and Simulation, which includes scenarios or envi- operate effectively. Medical teachers should be
Intensive Care ronments designed to closely resemble real-world aware of two main types of skills: technical
Teaching Hospital “A. Gemelli” situations, offers a safe environment within which (psychomotor) and non-technical (Reader et
Rome, Italy
learners can repeatedly practise a range of clinical al. 2006); the latter includes significant skills
Antonio Gullì, MD skills without endangering patients. Simulation that deserve specific mention like decision-
Anaesthesia and Intensive Care techniques have been used to teach all aspects making, flexibility, assertiveness, mutual respect,
Teaching Hospital “A. Gemelli”
of medical care, including knowledge, technical identifying priorities, situational awareness and
Rome, Italy
and non-technical skills. In addition, simula- fixation errors management. All these skills can
Massimo Antonelli, MD tion teaching has been identified as the optimal be effectively thought through and practised by
Chair instrument to control human factors and prevent simulation. Overwhelming compelling evidence
Department of Anaesthesiology and
Intensive Care Medicine
medical errors. highlights the importance of simulation-based
Teaching Hospital “A. Gemelli” Simulation is now widespread in many fields of training as a method to improve teamwork for
Rome, Italy human endeavour and its history stretches back patients’ safety.
over centuries. The modern aviation industry has
H istorically, medical education has

focused on the autonomy of health-
care providers, who are expected to
take care for a patient on their own. Conse-
quently, issues related to teamwork, multidisci-
developed high-fidelity flight simulation and has
led on improving the non-technical skills of teams
through crew resource management programmes.
Crew Resource Management (CRM) and Human
Factors (HF) are acronyms used by airlines
Centre for Simulation, Hospital A.
Gemelli
The Teaching Hospital “A. Gemelli” is located
in Rome, and incorporates several postgraduate
schools of medicine, including the School of
plinary and multi-professional interactions have designed for safety training and educational Anaesthesia, Intensive Care and Pain Manage-
not been explicitly and formally included in systems for high-risk industries. The basic concept ment. The training plan is competency-based
medical curricula. In addition, the hierarchical and mission of these training programmes are to and subject to satisfactory training progress and
organisation of medicine, mainly expressed reduce mistakes or errors, resulting in safer and assessment over a five-year programme; recently,
by a communication philosophy following a more efficient workplaces from fewer incidents the Centre for Simulation and continuous medical
chain of command, has strongly contributed and accidents. education has been created and simulation-based
to discouraging teamwork-based patient care. Anaesthesiology was one of the first medical training has been added to the students’ curric-
Healthcare providers are mainly trained as specialties to demonstrate the impact of human ulum. Serving both students and practising health-
individuals, yet work almost exclusively as teams, factors. Indeed, in the early 1990s, David Gaba care professionals from anaesthesia and intensive
showing a big difference between education and and colleagues, at Stanford University, designed care disciplines, the Centre is a central resource

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the practice and acquisition of clinical skills needed for patient care. Medical tion head for realistic respiratory simulation (intubation, NIV). It can also be
education is required for the learning and training period in order to ensure easily connected with a complete human body simulator.
patient safety especially in ICU. Artificial respiration education and proper The respiratory flight simulator combines high-end technical design and
setting of mechanical ventilation modes is primordial before application to mathematical modeling to create a complete solution for optimized learning
the patient. The training necessitates the use of realistically simulated patients of basic and advanced artificial respiration. It is the ultimate training tool for
in order to prepare to a variety of real scenarios. The latter are limited when anesthesiologists, intensive care physicians and nurses. Through a variety of
using mechanically lungs or animal-based training. preconfigured scenarios and spontaneous breaths, the simulation of acute
TestChest®, the physiologic controlled lung, provides a breakthrough in and chronic lung diseases is possible and real-time experience is guaran-
respiratory training and has the CE marking. It was developed by experts in teed. TestChest® realistically replicates pulmonary mechanics (resistance,
mechanical ventilation and respiratory physiology and is manufactured by non-linear compliance), gas exchange and hemodynamic responses. It has
Organis GmbH (Landquart, Switzerland) for worldwide distribution. a programmable FRC and allows the simulation of different types of sponta-
The simulation of human cardio-respiratory system is extremely realistic neous breathing to severely diseased lungs with operator-adjustable respiratory
and thus makes animal experiments for teaching purposes unnecessary. It can rate and occlusion pressure (P0.1).
Figure 1.
Figure 4.
Figure 2. Figure 1. the simulator consists of two bellows system driven by a linear motor. A large volume ensures
the simulation of a real human lung with realistic fRC and vital capacity. A basic control software cre-
ated by AQAi simulation Center (Mainz, Germany) allows the control of the motor and the setup of the
artificial lung parameters.
Figure 2.the motor realizes nonlinear s-shape of the pressure-volume loop, recruitment and collapse
of the lungs.
Figure 3. testChest® includes sensors for alveolar pressure, airway pressure, and environmental pressure as
well as an oxygen and temperature sensors. it is compatible with wet gases and it is equipped with a mass flow
controller for Co2 production, which together with an adjustable dead space permit the generation of realistic
capnograms.
Figure 4. An artificial finger allows the simulation of oxygen saturation curves. the variation of pulse ampli-
tude according to different intravascular fillings model heart-lung interactions supporting the testing of most
advanced closed-loop ventilation modes. the flight simulator offers for its pilots (healthcare professionals) a
realistic training environment to ensure the safety of patients.
Figure 3.
www.organis-gmbh.ch
78
MANAGEMENT
rooms, post-operative intensive care etc). 1990) and on reflective practice provides a
Sharing critical points raised during teaching conceptual model that guides teachers on
sessions is essential for learning in medical educa- how to discover the mental models that
tion settings. This is particularly true in simu- were used in guiding trainees’ actions during
lation-based medical education (SBME), which the teaching session. Trainees’ actions have
potentially creates high levels of stress in both always a logical sense if framed in the cogni-
instructors and trainees. tive model used to get a result. According to
Debriefing has been shown to be an essential this, mistakes are always or mainly caused by
part of the simulation-based learning process. meaning-making systems of the trainees, such
Savoldelli et al. (2006) demonstrated that simu-
lation without debriefing is ineffective, because
errors can be repeated if team members have not “Optimal to control human
been informed that they were making mistakes.
In the last 20 years, the judgmental approach
factors and prevent
to debriefing, mainly based on the “shame-and- medical errors”
blame” method, has been strongly criticised and
that provides state-of-the-art facilities and equip- discouraged because of its severe costs in terms
ment to support a variety of educational resources. of humiliation, frustration and depressed motiva- as their frames, assumptions, and knowledge.
ranging from basic psychomotor skills training tion (Leape 1994a; 1994b).The non-judgmental Using reflective debriefing the focus widens
to advanced, full-scale immersive simulation.The model to debriefing has been widely practised to include not only the trainees’ actions,
central idea is to integrate simulation immersion using different strategies and approaches, such but also their mental models that ultimately
into the education of future anaesthesiologists as as the Socratic model (leading questions and determined the final result. Mistakes are not
well as medical students and healthcare profes- “easing in”) (Argyris et al. 1985) or the sand- a source of shame and blame any more but
sionals in other specialties. wich model (good things followed by points of a precious learning resource to be openly
Simulation and CRM-based programmes improvement in a rigid sequence) (Weisinger acknowledged and discussed.
have been developed in the following areas 1989; Weisinger 2000). Transparent talk about trainees’ mistakes
and disciplines: Albeit the non-judgmental approach has the can be achieved by a three-step approach:
• Anaesthesia and Operating rooms scenarios significant advantage of not hurting trainees’ 1. Observation/description: the teacher
• Intensive Care Medicine feelings, it has some important weaknesses. First observes and describes the trainee’s action;
• Obstetrical Emergencies of all, it fails to openly disclose major problems 2. Comment/opinion: the teacher offers
• Paediatric and Neonatal Emergencies felt by both the teacher and the student. In other his/her ideas;
• In-Hospital trauma care words, always giving priority to positive aspects is 3. Mental model disclaimer: the teacher
• Cardiopulmonary resuscitation and acute often felt as artificial especially when a critical point shows his/her interest (curiosity) to
cardiac emergency care engages the trainee’s attention. In poor trainee discover the mental model that framed
• Rapid response systems performances, showing a relentless optimism the student’s action.
• Transport of critically ill patients may convey the embedded message that mistakes Reflective debriefing increases the chances
• Organ transplantation are not able to be discussed, or possibly shameful. that the student will be able to accept the
• Clinical toxicology “Reflective practice” is a term coined by teacher’s feedback without being defensive
• Disaster Medicine. Donald Schön (1983) to describe a method and feeling psychologically safe. It provides
Simulation resources include a full scale simu- to improve personal and interpersonal effec- trainees with a clear message about the
lation centre as well as an in situ Simulation tiveness of professionals by examining the instructor’s point of view while reducing
Programme by means of a fully self-sufficient wifi values, assumptions and knowledge base the background noise of misunderstandings
mannequin. Simulations can be performed in any that drives one’s own actions. Research and defensiveness that can be associated with
real clinical environment (operating rooms, A&E in cognitive science (Torbert 1972; Senge judgmental and nonjudgmental approaches.
References Alert, 21 July, issue 30. Associates, pp.13-25. senge PM (1990) the fifth discipline: the
Kohn Lt, Corrigan JM, Donaldson Ms, eds. Reader t, flin R, Lauche K et al. (2006) art and practice of the learning organiza-
Argyris C, Putnam R, smith DM (1985) Action
(2000) to err is human: building a safer health non-technical skills in the intensive care tion. new York: Doubleday.
science. san francisco: Jossey-Bass.
system. Washington, DC: Committee on Quality unit. Br J Anaesth, 96(5): 551-9. torbert WR (1972) Learning from experi-
Gaba DM, Howard sK, fish KJ et al. (2001)
of Health Care in America, institute of Medicine. savoldelli GL, naik vn, Park J et al. (2006) ence: toward consciousness. new York:
simulation-based training in anesthesia crisis
national Academy Press. value of debriefing during simulated Columbia University Press.
resource management (ACRM): a decade of
experience. simulation and Gaming, 32(2): Leape LL (1994a) Error in medicine. JAMA, crisis management: oral versus video- Weisinger H (1989) the critical edge: how
175–93. 272(23): 1851–7. assisted oral feedback. Anesthesiology, to criticize up and down your organization,
Leape LL (1994b) the preventability of medical 105(2): 279-85. and make it pay off. Boston: Little, Brown.
Joint Commission on Accreditation of Health
Care organizations (2004) Preventing infant injury. in: Bogner Ms, ed. Human error in schön D (1983) the reflective practitioner. Weisinger H (2000) the power of positive
death and injury during delivery. sentinel Event medicine. Hillsdale, nJ: Lawrence Erlbaum new York: Basic Books. criticism. new York: AMACoM.

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MANAGEMENT
COMMUNICATING ABOUT
DIFFICULT MEDICAL DECISIONS
THE MOST DANGEROUS PROCEDURE IN THE HOSPITAL?
Communication is central to the human experience of illness, and therefore central to medical decision-
making. Being an expert clinician now means being a skilled communicator. Fortunately, communica-
tion skills can be learnt, mastered and measured.
Peter G Brindley, MD, Furthermore, patients often come to intensive traumatic stress (eds Cyna et al. 2011; Dunn et
FRCPC, FRCP Edin care units (ICUs) following bad outcomes and al. 2007; Leonard et al. 2004). Communication
Professor, Division of Critical Care bad decisions: not just bad pathology. Therefore, can be a ‘placebo’ (i.e. good communication can
Medicine
we are as much a Relationship Repair Unit (i.e. reduce pain and anxiety) or ‘nocebo’ (i.e. bad
Adjunct Professor, Anesthesiology
and Pain Medicine an RRU) as an ICU (personal communication, J communication can increase pain and anxiety)
Adjunct Professor, Dossetor Ethics Ronco). Overall, communication becomes one of (eds Cyna et al. 2011). Better communication
Centre our most potent ‘therapies’, and how we coordinate might also decrease litigation and maintain hospital
University of Alberta
Edmonton, Alberta, Canada
(or fragment) ongoing care, bolster (or impair) reputation (eds Cyna et al. 2011). Accordingly,
cooperation, and grow (or erode) trust (eds Cyna communication is everybody’s business: it should
peter.brindley@albertahealthser-
vices.ca et al. 2011; St Pierre et al. 2008; Brindley and be taught to trainees, expected from practitioners
Reynolds 2011; Brindley et al. 2014; Brindley and supported by administration (eds Cyna et al.
Communication Matters 2010; Aron and Headrick 2002; Azoulay and 2011; St Pierre et al. 2008; Brindley and Reynolds
Communication is increasingly recognised as medi- Spring 2004; Azoulay et al. 2000). 2011; Brindley et al. 2014).
cine’s most important non-technical skill. Perhaps This review cannot exhaustively cover (or Communication is about listening as much as
this is self-evident: after all communication is how comprehensively reference) a topic as capa- talking. When we do talk it is also about more than
humans exchange meaning, reduce complexity, cious as communication. Therefore healthcare just what words are used (aka verbal communi-
address uncertainty, manage emotions, inform, professionals should read widely. The goal should cation) (St Pierre et al. 2008). We should also
encourage, comfort and challenge. Communication be to deliberately develop communication master good paraverbal communication: how words
is also central to the human experience of illness, skills throughout our careers: such that ‘verbal are said (pitch, volume, pacing and emphasis).
and therefore central to medical decision-making. dexterity’ matches manual dexterity and factual Moreover, while this review focuses on verbal
However, it is also complicated, nuanced and, know-how (eds Cyna et al. 2011; St Pierre et al. communication, non-verbal communication is
consequently, error-prone. Therefore it should 2008; Brindley and Reynolds 2011; Brindley et just as important. This includes appropriate body
not be left to chance, or always left to junior al. 2014; Brindley 2010). This is because being language, suitable eye contact, response to emotions,
team-members. Fortunately, communication can an expert clinician now means being a skilled the use of reflective silence and active listening
be learnt, mastered and measured (eds Cyna communicator (eds Cyna et al. 2011; St Pierre et (see below). We really cannot not communicate:
et al. 2011; St Pierre et al. 2008; Brindley and al. 2008; Brindley and Reynolds 2011; Brindley failing to make the effort sends its own message
Reynolds 2011; Brindley et al. 2014). et al. 2014; Brindley 2010; Aron and Headrick (eds Cyna et al. 2011; St Pierre et al. 2008; Brindley
If communication is defined as “sharing, uniting, 2002; Azoulay and Spring 2004; Azoulay et al. and Reynolds 2011; Brindley et al. 2014).
or making understanding common” (eds Cyna 2000). These skills will enhance difficult decision-
et al. 2011; St Pierre et al. 2008; Brindley and making: whether during acute medical crises; Why Communication (and Decision-
Reynolds 2011; Brindley et al. 2014), then better during handover with colleagues, or, as is this Making) Is Often Difficult
communication is key to creating systems that are article’s primary purpose, during discussions Shannon and Weaver, working for Bell Laboratories,
more trustworthy and patient-focused (eds Cyna with patients and surrogates. developed a model for verbal communication
et al. 2011; St Pierre et al. 2008; Brindley and still relevant to medicine decades on (St Pierre et
Reynolds 2011; Brindley et al. 2014). Whereas Medical Communication: The Basics al. 2008). Simply put, transmitters (i.e. speakers)
intensive care medicine previously focused on Communication skills are rarely innate, and do not encode messages, and receivers (i.e. listeners)
scientific discovery and technological advance, necessarily improve through years of unstructured decode them. However, both must be on the
medicine can also be understood as a complex experience (eds Cyna et al. 2011; St Pierre et al. same channel (which in medicine could mean
social system (Brindley 2010). Therefore intensive 2008; Brindley and Reynolds 2011; Brindley et possessing similar situational awareness and
care medicine should now also make a “science al. 2014). Similarly, communication is not one- emotional states), and there should be minimal
of reducing complexity” and a “science of size-fits-all, nor a panacea. However, commu- interference (which in medicine could mean
managing uncertainty” (St Pierre et al. 2008; nication training is associated with increased minimising chaos, stress, or cognitive bias). They
Brindley 2010). Much of this will be achieved confidence, improved patient satisfaction, less also identified the danger of ‘channel-overload’
(or squandered) by how well we talk and listen. anxiety, decreased depression and lower post- (which in medicine warns against communication

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MANAGEMENT
that is unnecessarily complex). Overload, which expectation, and previous interactions (St Pierre they (or we) expected (“he said X, but I know
often results in indecision, also occurs unless the et al. 2008). Notably the sender cannot fully force what doctors mean”). Incongruence promotes
receiver can filter data into usable information: the listener’s mind (and vice-versa). A practical misinterpretation, and can be interpreted as
You receive data (“his blood pressure is low”), example follows: disingenuous (eds Cyna et al. 2011; St Pierre et
but need to create usable information (“his body When a doctor says to a patient or surrogate: al. 2008; Brindley and Reynolds 2011). Congru-
is failing”) (St Pierre et al. 2008). “What do you want me to do?” the doctor ence is even more important when those involved
Shannon’s model has limitations. Complex may presume he asked a unambiguous ques- are unfamiliar, or when the medical situation is
communication also requires meaning, which tion which respects autonomy. Perhaps he novel, which is almost always for families! Investing
did, but intonation can suggest otherwise. the time to establish ‘rapport’ (usually defined as
He may also have revealed his inability to ‘common perspective’; ‘being in sync’ or ‘shared
“Communication becomes one make difficult decisions or even frustration mental model’) can facilitate all future interac-
of our most potent ‘therapies’” about the patient’s premorbid state (“it’s
too late...what do you expect me to be able
tions (eds Cyna et al. 2011; St Pierre et al. 2008;
Brindley et al. 2014). The effort demonstrated can
to do!”). Also, the doctor’s self-revelation also reinforce the patient’s psychological reserves
is harder to encode, transmit and decode. This is could be one of either appropriate patient and resilience (eds Cyna et al. 2011; St Pierre et
one reason why we cannot assume that patients concern or resignation (“I don’t have the al. 2008; Brindley and Reynolds 2011).
and surrogates have reached the same conclusion time/training/authority for these complex
as medical practitioners (St Pierre et al. 2008). cases…just tell me what do you want”). His Helping Patients and Surrogates Feel
This in turn explains why doctors are commonly request or appeal (albeit unstated) might be Safe to Communicate
criticised for failing to say what they mean, or to try to subtly persuade the family (“I’m not As popularised by Pincince (2013) and others,
mean what they say (“did you ever actually say ‘he sure ICU would be best”). In contrast, senior decisions are best made when people are not in hot
is dying’?”). This model also describes communi- doctors may wish to minimise the patient/ emotional states (anger, stress). To ‘cool’ emotions,
cation as unidirectional (transmitter to receiver), surrogate’s sense of responsibility/guilt. In this patients and surrogates need familiarity, which can
whilst medical decision-making is commonly case, communication should unequivocally state be undermined by changing staff too frequently;
multi-directional, across disciplines and across what they believe is not appropriate but also predictability, which can be threatened by keeping
hierarchies (St Pierre et al. 2008; Brindley and what can be done (“life support doesn’t treat families waiting; intact support systems, which
Reynolds 2011; Brindley et al. 2014). Location this so won’t be offered. Instead, we will treat can be destabilised if families feel excluded and a
should not affect data transmission, but it affects reversible conditions and maintain comfort”). sense of control, which can be weakened by illness
communication quality, impact and efficiency. For The surrogate decision-maker also listens with and unfamiliarity. Hot emotional states lead to
example, when transmitter and receiver are no four ears, and any one can be more or less open. anger or intransigence (aka ‘neural hijacking of the
longer face to face communication loses impor- For example, a content-based response would rational brain’).The psychologist Stephen Porges
tant non-verbal cues (St Pierre et al. 2008). This respond with objectivity (“I want everything”). explains this idea using the polyvagal theory: when
is why the medical telephone call is important If the family member hears the self-revelation he calm our vagus nerve can facilitate engagement;
to practise, and why confirming understanding might reply: “she’s been through a lot, but she’s a when angry it stimulates conflict ( Porges 2011).
by routinely summarising and repeating back is fighter”. If the family member is attuned to rela- These ideas apply to those that cannot talk
an important fail-safe (eds Cyna et al. 2011; St tionship aspects, or has previous disappointments (endotracheal tube; stroke), and those that do
Pierre et al. 2008; Brindley and Reynolds 2011; from the medical professions, then they may be not talk (fear, confusion, deference) (eds Cyna
Brindley et al. 2014). more defensive (“You doctors give up too easily: et al. 2011; Brindley et al. 2014). For patients
Newer communication models focus on I want everything”). Only rarely will the listener already burdened with illness, not being able to
relationships, not just tasks. The ‘four mouths have the state of mind to decipher the appeal: “so verbalise, and not being understood, can accel-
and four ears model’ (St Pierre et al. 2008) has what I think you’re telling me is..”. Regardless, this erate a downward spiral into frustration and
sender and listener separated by a message with model shows how communication can create a disengagement. Also when healthcare workers
four equal sides: i) content; ii) relationship; iii) virtuous cycle that builds cooperation, or a vicious do speak we may speak differently than patients
self-revelation iv) appeal (St Pierre et al. 2008). cycle that destroys it (St Pierre et al. 2008; Brindley (eds Cyna et al. 2011). Physicians often use
Content refers to facts and words. The relationship and Reynolds 2011). technical language and focus upon gathering
aspect means that senders reveal (consciously Communication is affected (both in meaning information and delivering news. Patient language
and unconsciously) how they regard receivers and interpretation) by the paraverbal (volume, and surrogate language often focuses on beliefs,
through specific words, intonations and non- tone, pitch, pacing) and non-verbal (angry eyes; fears and hopes, which explains why they may
verbal signals. Senders also indicate how they furrowed brow) (eds Cyna et al. 2011; St Pierre et cling onto any positive news (“so it’s not the
feel about themselves, namely a ‘self-revelation’. al. 2008; Brindley and Reynolds 2011). These in worst you’ve ever seen!”). Patient and surrogate
Fourthly, there is an appeal (or request) where turn are affected by subconscious emotions and coping strategies may include denial or aggres-
messages encourage the receiver to do (or not attitudes. If verbal and non-verbal are incongruent sion, whereas caregivers intellectualise to protect
do) something. These four aspects apply to both (words say one thing; expressions another), then emotions. Communication that is sensitive, but
talker and listener, namely we ‘speak with four receivers typically deemphasise words, and amplify objective, can bridge the caregiver’s ‘scientific
mouths’ and ‘listen with four ears’. This is often the importance of tone and body language. With world’ and the care-receiver’s ‘natural world’
unconscious, and depends upon mental state, incongruence receivers typically default to what (eds Cyna et al. 2011; Brindley et al. 2014).

82
MANAGEMENT
Communication Tools That Can Aid within 72 hours: i) family meeting, ii) discuss least as much as their technical skills (Heyland et al.
Decision-Making prognosis, iii) assess patient-specific goals, and 2002). For difficult decision-making (and even for
Especially when communicating bad news, doctors iv) offer spiritual care. This approach emphasises simple decision-making!) communication is likely
and nurses should understand that, while routine for that decision-making requires more than just data our greatest clinical asset, or keenest liability.
us, for families these are sentinel moments, unlikely transmission. Patients are validated as people with
to be forgotten (eds Cyna et al. 2011; Brindley et values (not just diseases) and part of a larger ‘life- Note
al. 2014). Combined with ‘active listening’ (where support system’ that includes family, friends and This article is adapted from a more comprehen-
listeners pay close attention and use feedback or community (eds Cyna et al. 2011; Brindley et al. sive review of high-stakes medical communi-
rephrasing to demonstrate engagement and under- 2014 Black et al. 2013; Davidson et al. 2007). All cation in the Handbook of Intensive Care Organization
standing), the effort put into communication is a of the above should also explain why patients and and Management (Editors A. Webb and G. Ramsay;
way to demonstrate non-abandonment (eds Cyna surrogates value clinicians’ communication skills at publication pending).
et al. 2011; Brindley et al. 2014). Communication
tools and bundles (see below) can also provide
structure and reliability to complex communica-
tion. However, they should never make interactions The Calgary-Cambridge guide (Silverman et 3. Utilisation (of appropriate words);
robotic and devoid of personal connection. al. 2005; Kurtz et al. 2003) divides communi- 4. Reframing, and
We also have tools to audit communication with cation into: 5. suggestion.
patients and surrogates (Black et al. 2013; Davidson 1. initiate;
et al. 2007). Black et al. (2013) promoted a commu- 2. Gather information; The VALUE acronym (eds Cyna et al. 2011; Curtis
nication bundle with six requirements within 24 3. Provide structure; and White 2008) divides communication into:
hours: identification of i) the surrogate-decision 4. Build relationships; 1. value statements from family;
maker; ii) code status; iii) advance directive; iv) 5. Explain and Plan, and 2. Acknowledge emotions;
pain v) dyspnoea, and also vi) distribution of a 6. Close the session. 3. Listen;
brochure. Four additional goals should be met 4. Understand the patient as a person;
The GREAT acronym (eds Cyna et al. 2011) 5. Elicit questions can facilitate shared
consists of: decision-making.
Key Messages 1. Greetings/Goals;
• Communication is central to the 2. Rapport The SPIKES acronym is recommended when
human experience of illness, 3. Evaluation/Expectation/Examination/ delivering bad news (eds Cyna et al. 2011; Baile
and therefore central to medical Explanation; et al. 2000), and divides communication into:
decision-making. 4. Ask/Answer/Acknowledge; 1. settings;
• Being an expert clinician now 5. tacit agreement/thanks. 2. Patient perception;
means being a skilled communi- 3. invite to share;
cator. The LAURS acronym (eds Cyna et al. 2011) 4. Knowledge transmission;
• fortunately, communication consists of : 5. Emotions and Empathy;
skills can be learnt, mastered and 1. Listening; 6. summarise and strategise.
measured. 2. Acceptance;
References ance with process measures for iCU clinician critical care: a practical guide to exploring the Leonard M, Graham s, Bonacum D (2004) the
communication with iCU patients and families. art. oxford, new York: oxford University Press. human factor: the critical importance of effective
Aron D, Headrick L (2002) Educating physi-
Crit Care Med, 41(10): 2275–83. Davidson JE, Powers K, Hedayat KM et al. (2007) communication in providing safe care. Qual saf
cians prepared to improve care and safety is
Brindley PG, Reynolds sf (2011) improving verbal Clinical practice guidelines for support of the Health Care, 13(suppl 1): i85-90.
no accident: it requires a systematic approach.
Qual saf Health Care, 11 (2): 168–73. communication in critical care medicine. J Crit family in the patient-centered intensive care unit: Pincince M. Hot and cold emotional states [video]
Care, 26(2): 155-9. American College of Critical Care Medicine task [Accessed: 18 March 2015]. Available from https://
Azoulay E, spring CL (2004) family-physician
Brindley PG, smith KE, Cardinal P et al. (2014) force 2004–2005. Crit Care Med, 35(2): 605-22. www.youtube.com/watch?v=KsAfq5G5fgc
interactions in the intensive care unit. Crit Care
Med, 32(11): 2323–8. improving medical communication: skills for a Dunn EJ, Mills PD, neily J et al. (2007) Medical Porges s (2011) the polyvagal theory. neuro-
complex (and multilingual) world. Can Respir team training: applying crew resource manage- physiological foundations of emotions, attach-
Azoulay E, Chevret s, Leleu G et al. (2000) Half
J, 21(2): 89-91. ment in the veterans health administration. Jt ment communication and self-regulation. new
the families of iCU patients experience inad-
Brindley PG (2010) Patient safety and acute Comm J Qual Patient saf, 33(6): 317-25. York: norton.
equate communication with physicians. Crit
Care Med, 28(8): 3044–9. care medicine: lessons for the future, insights Heyland DK, Rocker GM, Dodek PM et al. (2002) silverman J, Kurtz s, Draper J (2005) skills for
from the past. Crit Care, 14(2): 217. family satisfaction with care in the intensive communicating with patients. 2nd ed. oxford:
Baile Wf, Buckman R, Lenzi R et al. (2000)
Curtis JR, White DB (2008) Practical guidance for care unit: results of a multiple center study. Radcliffe Medical Press.
sPiKEs – a six-step protocol for delivering bad
evidence-based iCU family conferences. Chest, Crit Care Med, 30(7): 1413-18. st Pierre M, Hofinger G, Buerschaper C et al.
news; application to the patient with cancer.
oncologist, 5(4): 302-11. 134(4): 835–43. Kurtz s, silverman J, Benson J et al. (2003) (2008) Crisis management in acute care settings:
Cyna AM, Andrew Mi, tan sGM et al., eds. (2011) Marrying content and process in clinical method human factors and team psychology in a high
Black MD, vigorito MC, Curtis JR et al. (2013)
Handbook of communication in anaesthesia & teaching: enhancing the Calgary-Cambridge stakes environment. new York: springer.
A multifaceted intervention to improve compli-
guides Acad Med, 78(8): 802-9.

84
INTERVIEW
PARTNERING MEDICINE
AND PUBLIC SERVICE
INTERVIEW WITH PROFESSOR PAUL E. PEPE
Paul E. Pepe, MD, MPH, is Professor with Tenure in Internal Medicine, Surgery, Pediatrics, Public Health &
Emergency Medicine (EM) at UT Southwestern and the City of Dallas Director of Medical Emergency Services
for Public Safety, Public Health & Homeland Security. Up until this spring, he served for more than a decade
as the jurisdictional Medical Director for the regional EMS system (about 250,000 annual emergency inci-
dents, involving about 3,000 paramedics/first responders in Dallas and 18 surrounding cities) and he was
recently appointed to become Regional Director for Out-of-Hospital Mobile Care Systems and Disaster/
Event Preparedness at the University, a state government institution. For the past three and half decades, he
methodically brought critical care medicine to the streets of North America in cities such as Seattle, Houston
and Dallas where he has practised on-scene prehospital medical care and conducted ground-breaking inves-
tigations. Prof. Pepe joined the Editorial Board of ICU Management in 2014.
Over the past 18 years, you have combined only facilitated by researchers who routinely exception to informed consent (ETIC) due
an academic chair role in emergency evaluate interventions scientifically, be they to the nature of the life and death decisions
medicine with public service roles in medical care or procedural innovations, but that need to be made within minutes – or
emergency medical services. How does also by their ability to secure extramural even seconds. Even if the family were present,
practice inform research in these roles? funding and grants. any consent would be given under duress
Participation in academia and in public When you have visionary public officials, and therefore would not be considered truly
service is complementary in many ways. In those changes can be implemented more informed consent.
academia, our purpose is to scientifically rapidly, particularly when the data are gener- In turn, there are now accepted policies
make improvements in patient care and teach ated to back up the funding needs and resource to provide ETIC under such circumstances.
those advances to the trainees, but, in the allocation. A classic example is in the arena Nevertheless, to politically, sociologically and
end, the mission is to serve the public. Public of resuscitation medicine. Public resources ethically conduct a study involving ETIC,
officials are, de facto, serving the public, and (e.g., paramedics and first responders) can it is critical to have the involvement and
so there is a common mission. I have been be used to research how to save more lives prospective knowledge and consensus of
very fortunate to work with visionary elected in the realm of cardiac, trauma and STEMI public officials, the medical community, the
and managerial public officials, who have resuscitation as well as stroke recovery and media and other advocates for our patients.
seen the benefits of working hand in hand a myriad of other critical illnesses and inju- By being an integral and trusted part of
with academia. The academic world has the ries. In order to conduct scientific studies local government, one can communicate and
tools to study, document and verify appro- in patients with these critical conditions, interact with other public officials, the media
priate uses of public resources. This is not it often entails the need to implement an and public health officers on a regular basis,

85
INTERVIEW
thus facilitating that trust and a working media in our efforts to study life-saving nity consultation committee. The committee
knowledge of activities. This is very impor- interventions. Long before we began to do is made up of news directors, elected offi-
tant because public leaders are incredibly clinical trials, I started working with the cials, congress members, county supervisors,
busy and are continually bombarded with county and city governments and news media the medical society and public health offi-
multiple other proposals to analyse. To have alike. Even then, I was explaining to them cials. We actually have great discussions and
a daily interface, even if briefly, enhances the the inadequacies of historical controls and everyone loves to come to these meetings
ability to get things explained, accepted and why you need prospective controlled studies. of the minds. We have convened this group,
accomplished. For example, we had an incident We also educated them how the design of not only regarding research, but also to talk
where we were going to be dismissed from a clinical trials would not only be done in a about things like what are we going to do if
particular clinical trial by the national centre fair manner, but that everyone, including there is a big pandemic or nuclear explosion
because of lack of compliance in a particular traditionally underserved populations, would and how we plan to organise – and triage
metric. A single phone call to the lead public get equal access. In other words, everyone – in mass critical care scenarios. Because of
official in the city was able to turn things gets a 50/50 shot at the new intervention these thoughtful joint discussions about these
around by prioritising the focus on meeting regardless of who they are. sensitive issues, we have helped to pre-empt
those compliance standards despite being in Most importantly, we have documented knee-jerk responses to well thought-out strate-
the midst of budgetary crisis. That would not dramatic improvements in outcome for the gies. Instead of being criticised after the fact
have happened had I not been part of that control group simply because of implementing in a very shallow way that we are creating
government organisation on a day-to-day the trial. When I introduce any new studies ‘death panels’, or that we are experimenting
basis and gained the respect and confidence we are doing, I always explain what happened and treating people like ‘guinea pigs’, these
of the final decision makers. with the last one. Consistently, and regardless public advocates come to better understand
This association between academia and of the study outcome, the survival chances go the process, intent and wisdom of what we
public service also benefits the tax-paying up for everyone who was enrolled, whether are planning – and not under the duress of
citizens at large, because our ability to bring they were in the control or study group. an actual event. More importantly, they help
in extramural grants means that we can imple- Also, when I am examining the ethical and to guide us in a very responsible manner.
ment changes and obtain new life-saving scientific decisions about whether I should They know how carefully we arrived at some
equipment and monitoring devices to help conduct a trial, I always ask myself, “Would I very difficult conclusions. Accordingly, I make
better document the life-saving interventions enter my child or my mother in this study?” sure that it is well known that the public
and procedures. As a result, over the past When I can truly feel that way and articulate it officials and the media were partners in the
ten years, we have been able to demonstrate accordingly, there is immediate “buy-in” now. life saving effects in this community and that
dramatic improvements in survival for condi- Armed with the prior study’s data and they should be credited for their wisdom and
tions such as cardiac arrest, STEMI, stroke and earning their trust over the years, it helps visionary involvement.
trauma and at no direct cost to the citizens me to accomplish even more life-saving – all Also, I often point out that in day-to-day
in our community. It is a public official’s because I had established longstanding routine emergency care, the treatment you might be
dream to be able to improve public safety interactions with other public officials, the provided is generally not known to the average
and public health without costing anything, media and, in turn, the public at large. person or that it may be altered depending on
so a mutually beneficial two-way street is the practitioner involved. When I do the study,
facilitated by my living in those two worlds however, the protocol is public record and
simultaneously. “A good leader is basically people know exactly what we are going to be
a person who is trusted”

doing. So the care provided is quite transparent.
You are on record as “proud to serve” as Secondly, everybody in this community, no
a public servant. You are also generous matter what background they come from,
with your time in talking to mass media. is treated the same way. For example, when
Why are these roles important for a In terms of a specific new study, education we talk about the issue of mass critical care
physician? of media and public officials cannot be done in which we may have to make some very
When people ask what I do for a living, by someone they barely know in a quick difficult triage decisions, we point out that
the reply that comes to mind first is “I’m sound bite manner, whether for a first-time our consensus-based protocols are available
a public servant”. I have worked for state press conference or for a public committee to the public at large and everybody will be
and/or municipal governments for the last meeting. One needs to educate those public treated the same way. In other words, wealth
30 years. It just happens that I have some advocates well ahead of time. I usually do will not determine the level of care. Instead, we
special talents or competencies in the realm it one-on-one with each of them, making created a level playing field and this engenders
of medical care. Even if I were not working in the rounds to each TV news director or city additional trust. Again, pre-emptive education
government, I still see my role as a physician council member. Eventually, I usually bring of the community consultation committee
as providing service to the public. these leaders together in a closed conclave in members will help to significantly mitigate
In Dallas, we have partnered with the mass one room for what I call the Dallas commu- mistrust in a future crisis.

86
INTERVIEW
What should future priorities be for How do you define success in an EMS/ a profound experience when every one of
cardiac and resuscitation research? ICU director? them is not only saved, but is waking up
What I am currently working on involves One of the things I have learned is that before arrival of paramedics. That was a classic
different ways to actually improve flow even where we thought that improved survival example of “the earlier an intervention the
further. I am beginning to focus on situations rates, improved protocols and cost-effective better the results” and also the corollary,
in which there has been a really serious anoxic procedures were traditionally thought of as “a gram of good prehospital care saves a
insult, particularly in those who have had a defining success of a medical director for kilogram of ICU care” (Caffrey, et al. 2002).
long cardiac arrest interval, say 5, 10, or 15 a critical care unit, whether the unit is a Another example is using Continuous Posi-
minutes without any intervention. typical ICU unit or one out on the streets, tive Airway Pressure (CPAP) in the field; we
In the past, such conditions would have success is actually how you deal with and have learned that if we introduce CPAP early
been seen as irretrievable. However, our new navigate through the daily political, and/or on we can prevent intubations. This means
intrepid experiments show a different way logistical problems that come up - whether not only taking CPAP to the streets and in the
of thinking about things – instead of a focus it’s patient complaints, budgetary obstacles ambulance, but into homes. With portable
on restoring an adequate coronary perfusion or bad interactions with colleagues. How you CPAP devices, we were able to prevent several
pressure, I am thinking about restoring better handle those different obstacles on a day-to- hundreds of people from being intubated,
coronary and systemic flow. day basis is what really defines a good leader. once again because the earlier the interven-
Without getting into the specifics of what Some might also say that critical care medical tion, the better result. By acting, literally
we are doing, I would simply point out that directors (be it EMS or ICU) who handled within minutes, before the flash pulmonary
we now believe that we may indeed be able those obstacles and challenges well served oedema can progress too far, it is easier to
to resuscitate and send home persons neuro- for long periods of time and thus were able reverse. The reason why this is so impor-
logically intact despite such anoxic insults. to have the better opportunity to improve tant is that it not only spares ICU resources,
Consequently, we will increase survival rates outcomes. Leadership doesn’t require just personnel and equipment, leaving ICU beds
even further because we are dealing with being a nice person. It also requires being open, but it also prevents complications such
a very large population of patients who competent, having the data and at the same as ventilator-associated pneumonia (VAP).
currently do not survive. time being willing to understand the other As we are supposed to be accountable care
person’s side and needs and being able to organisations nowadays, this intervention
What are the most promising technolo- accomplish mutual goals for the patient’s does exactly what we want; we save money,
gies for EMS? sake. Ultimately it means being seen as a spare resources and decrease the incidence of
We are now beginning to show that quality sincere patient advocate and not just someone complications such as VAP. But, most impor-
CPR monitoring devices and flow-enhancing looking out for his or her own needs. Simply, tantly, we improve patient satisfaction. If this
adjuncts, such as the active compression- you are a team looking out for the patients. was my mother and she suddenly has flash
decompression pump and the impedance What defines a good leader is basically a pulmonary oedema and is drowning, she
threshold device, improve outcomes. Another person who is trusted. is terrified. But, then, if we have to come
tec hnology that shows promise is Trans- along and put a tube in her lungs in a very
Oesophageal Echocardiography (TOE), because it You say that a gram of good pre-hospital care dramatic moment at the hospital, because of
may help us to see if the heart is still beating saves a kilogram of ICU care. Why is that? progressing lung and heart failure, she may
in the absence of a detectable pulse. Also, My mantra over the years has been, “the earlier ask to just let her die next time. Instead, today,
if we see that the heart is not beating we the intervention, the better the results”. For we can come along and put a noninvasive
can feel more comfortable in terminating example, we introduced automated defibril- mask on the patient’s face, and in moments
resuscitation efforts. The most interesting lators at the airports in Chicago fifteen years they begin to feel much better.
and latest twist is that, with TOE, you may ago. In the first year of implementation all In the end, that to me is what it is all about
find the most optimal position to place one’s nine people who collapsed in the counter — providing better care for our patients and
hands in order to improve the vector of the and gate areas, where we had placed devices, not just better management or treatment for
outflow during CPR. Perhaps, eventually, survived neurologically intact. Most of them our patients.
with other adjuncts, we will be able even were waking before traditional EMS arrived.
to look at how we are improving blood In the past, even if there was bystander CPR
brain flow. In terms of the quality of CPR, and rapid resuscitation by the medics, the
we really have started to do some fine tuning patients still would be in a coma and remain
that has saved lives. For example, the so-called in coma requiring intubation and mechanical
“sweet spot” of chest compression rate might ventilation in the ICU. Half of them would
Reference
be around 110 with standard CPR, but with wake up — and half of them would not. Now, Caffrey sL, Willoughby PJ, Pepe PE et al. (2002) Public use
adjuncts such as the impedance threshold with such an intervention being provided of automated defibrillators. n Engl J Med, 347(16): 1242-7.
device, that rate might be 90. so much earlier, by the public no less, it is

88
COUNTRY FOCUS: KOREA
CRITICAL CARE MEDICINE IN KOREA

THE PAST, THE PRESENT AND THE FUTURE
Dong Chan Kim, MD KSCCM was established on 19 December 1980 April 2008, the KSCCM started the critical care
President by over 30 founding members. Although the specialty board of Korea, which was endorsed by
Korean Society of Critical Care
pioneers of critical care in Korea were anaes- the Korean Academy of Medical Societies.The critical
Medicine
Professor thesiologists, the founding members of KSCCM care subspecialty is supposed to be renewed every
Department of Anesthesiology & came from many different specialties (emergency five years. With the stimulus from the critical care
Pain Medicine medicine, surgery, pulmonology, cardiology and specialty board, a formulated critical care training
Chonbuk National University Medical
paediatrics). The first chairman of the board was system has been implemented in Korea, mostly in
School & Hospital
Jeonju, Korea Dr. Lee HJ, a cardiologist (the first president was teaching hospitals. The number of board-certified
dckim@jbnu.ac.kr Dr. Kim WS). The number of KSCCM members intensivists has increased to 1399 in 2015.
has expanded to approximately 1900 in 2015 To ensure education of the trainees, two review
(see Figure 1). courses are provided by the KSCCM. One is the
The first Scientific Congress of KSCCM was Basic Critical Care Review Course (BCCRC), which
held in 1981 and the Korean Journal of Critical was started in 2008; the other is the Multiprofes-
Sungwon Na, MD
Secretary General
Care Medicine (http://www.kjccm.org) started sional Critical Care Review Course (MCCRC) Korea.
Korean Society of Critical Care publishing in 1986. In 2004 the 13th Congress
Medicine
Associate Professor
of the Western Pacific Association of Critical “A formulated critical care
Care Medicine was held in Seoul, focusing on
Department of Anesthesiology and
Pain Medicine "Mutual Understanding and Development in training system has been
Yonsei University College of Medicine WPACCM". Over one thousand attendees partici-
Seoul, Korea pated in the congress. implemented”
silkena@gmail.com
Critical Care Medicine Specialty Board International Relationships

and Training System Joint Congress of the KSCCM and the Japanese
The Textbook of Critical Care Medicine was published Society of Intensive Care Medicine (JSICM)
History of Critical Care in Korea and by the KSCCM in 2006, which is the cornerstone The first joint congress of the Korean and Japa-
the Korean Society of Critical Care of training for the critical care board. On 15 nese societies was held in 2001 in conjunction
Medicine
The first intensive care unit (ICU) in Korea
was established in 1968 with six beds in a
university hospital in Seoul, and the number
has since expanded to 220 ICUs taking care of
3197 patients (data from a one-day survey in
2009). As in other countries, such as Dr. Peter
Safar in the United States and Dr. Bjorn Ibsen
in Denmark did in the early 1950s, anaesthe-
siologists played an important role in starting
critical care in Korea. The first ICU in Korea
was established and run by an anaesthesiolo-
gist, Dr. Oh HK.
The foundation of the Korean Society of Critical
Care Medicine (KSCCM) (http://ksccm.org/
eng) accorded with the foundation of the Western
Pacific Association of Critical Care Medicine
(WPACCM). Korean delegates attended the
meeting of the WPACCM, which was held in
Figure 1. number of KsCCM Members
Tokyo on 26 July 1980. After the meeting the

89
with the 20th anniversary of the KSCCM. The

Statistics
two societies decided to continue the biennial
joint congress and now the hosting society takes total population (2013) 49,263,000
turn every year. The alliance between the two
Gross national income per capita (PPP international $) (2013) 33,440
countries has evolved into performing joint
collaboration research. The first collaborative Life expectancy at birth m/f (years) 80/84
research was published in Critical Care in 2012
(Lee et al. 2012). Life expectancy at birth m/f (years) 78/85
2,321
Multiprofessional Critical Care Review Course Probability of dying between 15 and 60 years m/f (per 1,000 population)
(MCCRC) Korea
The Multiprofessional Critical Care Review Course total expenditure on health as % of GDP 7.5
(MCCRC) Korea began in September 2009 in
Asan Medical Center. The MCCRC is held by Source: World Health organization Health observatory http://www.who.int/countries/kor/en/
the Society of Critical Care Medicine (SCCM) statistics are for 2012, unless otherwise stated.
in collaboration with partnering critical care
Directory
societies worldwide. The MCCRC Korea was the
Korean society of Critical Care Medicine
first review course run outside of the United Future Initiatives of KSCCM http://ksccm.org/eng/
States by SCCM and now it has spread to Saudi The KSCCM has conducted much of its work to
Korean society of Anesthesiologists
Arabia, Japan, China, and Brazil. set up a high standard of critical care in Korea. http://www.anesthesia.or.kr/eng/
Improving patient safety and patient/family-
Korean society of Emergency Medicine

World Federation of Societies of Intensive and centered care should be the future directive of http://www.emergency.or.kr/english/
Critical Care Medicine (WFSICCM) KSCCM to achieve this mission. Moreover, the
In 2015 the 12th Congress of the WFSICCM nationwide spread of standardised care in ICUs Reference
will be held in Seoul, Korea, with the motto based on the best available evidence could be the Lee BH, inui D, suh GY et al. (2012) Association of body
of “One Step Further: the Pursuit of Excellence starting point of better healthcare in Korea. The temperature and antipyretic treatments with mortality
of critically ill patients with and without sepsis: multi-
in Critical Care”. Over four hundred abstracts KSCCM has also developed partnerships with
centered prospective observational study. Crit Care,
have been submitted, and approximately 220 societies in developing countries by providing 16(1): R33.
speakers have accepted invitations so far. educational opportunities.
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90
HOT TOPICS IN CRITICAL CARE

MEDICINE IN KOREA
will be more than 100 sessions in a variety Seoul 2015 Congress will become essential
of topics in multiple formats at the Seoul on account of its coordination function
Dong Chan Kim, MD congress. And approximately 280 speakers and responsibility in providing the most
President of the Korean Society of
Critical Care Medicine and chairs from 50 countries have accepted up-to-date information to meet the needs
Professor invitations so far. of participants from all over the world.
Department of Anesthesiology & The WFSICCM Seoul 2015 Congress is
Pain Medicine
being prepared under two main themes:
Chonbuk National University Medical
School & Hospital ‘One Step Further’: The first theme brings “large variability in the
Jeonju, Korea forward a message that WFSICCM Seoul
dckim@jbnu.ac.kr 2015 is the place where all participants can number of ICU specialists”
improve their medical abilities in a practical
manner and further advance mutual under-

standing with other critical care providers Variability of Standards among ICUs
Sang-Min Lee, MD working in different circumstances. in Korea
Director of Academic Board of Ko-
‘Get Together’: Under this second theme, Currently one of the important problems
rean Society of Critical Care Medicine
Associate Professor we have supported intensivists from coun- is the variability of standards among ICUs.
Division of Pulmonary and Critical tries with limited medical resources in their There is especially large variability in the
Care Medicine participation in the WFSICCM Seoul 2015 number of ICU specialists, because we do
Department of Internal Medicine
Congress. Supported physicians and nurses not have legal obligations for intensivist
Seoul National University College of
Medicine from resource-limited countries will obtain staffing (see Table 2). We still need more
Seoul, Korea practically usable knowledge throughout intensivists now. However, insufficient reim-
sangmin2@snu.ac.kr the sessions. During the sessions such as bursement has led to the fact that hospital
‘Meet the Experts’, ‘Panel Discussions’ and management does not want to invest in ICUs.
‘Workshops’, they can share with other In addition the patient-to-nurse ratio is
participants and field experts medical case highly variable according to ICU type and
studies or difficulties they have faced in hospital size. The shortage of ICU nurses
12th Congress of World Federation their countries. has increased workload and led to burnout.
of Societies of Intensive and Critical In addition a number of workshops will We have a high turnover rate of ICU nurses.
Care Medicine (WFSICCM) be organised during the main congress to
This year, the 12th Congress of the World help participants attend the sessions more Quality Assessment for ICUs in
Federation of Societies of Intensive and conveniently. These sessions are designed to Korea
Critical Care Medicine (WFSICCM Seoul inspire participants to learn novel knowl- Given that the reimbursement system is
2015 Congress), in collaboration with the edge while experiencing new devices and ‘fee-for-service’ in Korea, there is a risk
World Federation of Critical Care Nurses medical technologies. of providing more healthcare services than
(WFCCN) and the World Federation of Pedi- The Committee promises to put its utmost needed, or there being unacceptable variation
atric Intensive and Critical Care Societies effort to provide the high-quality experience of healthcare services between institutions.
(WFPICCS) will be held from August 29 of large-scale exhibitions and also enjoy- The Quality Assessment Service is a systematic
to September 1, 2015 in Seoul, Korea. This able social events where you can establish method of assessing the clinical validity and
will be the second time the congress is held a new global network. cost efficiency of medical and pharmaceutical
in Asia, where intensive and critical care With a view to highlighting the role of services, which is conducted by the Health
medicine has undergone a marked develop- the Korean Society of Critical Care Medi- Insurance and Review Assessment Service
ment over the past decades. cine (KSCCM) as an invaluable source of (HIRA). From 2000 to 2013, a total of 30
The total number of submitted abstracts support in advancing science and educa- items, including acute diseases, chronic
to the WFSICCM Seoul 2015 Congress is tion throughout Korea and beyond, we feel diseases and degree of service utilisation
560 from 47 countries (see Table 1). There more than convinced that the WFSICCM has been assessed. Finally, quality assessment

91
Continent Country Abstracts
Africa (11) Egypt 2
Ethiopia 1
Nigeria 4 for ICUs was carried out from October • ICU re-admission rate within 48h of
South Africa 3 to December 2014. ICU discharge;
Uganda 1 All ICUs of general or teaching hospitals • Rate of central venous catheter-related
were subject to assessment. Quality assess- blood stream infection;
Asia & Middle Bangladesh 1
East (476) ment indicators were used to describe the • Rate of ventilator-associated pneu-
China 23
structure, process and outcomes. Some monia et al.
examples of quality assessment indica- Assessment results will be disclosed to the
China, Hong Kong 2
tors were as follows: public in late 2015.
India 21 • Intensivist staffing; We hope that this quality assessment service
Indonesia 12 • Patient-to-nurse ratio; will minimise the variance of ICU treat-
Iran 1 • Reporting and analysis of standardised ment among institutions and improve the
Israel 2 mortality ratio (SMR); quality of ICU care in Korea.
Japan 103
Korea, Republic of 208
Malaysia 1
Total No.
Nepal 3 Empowered Full-Time
of Units MD MD
Pakistan 10 Responding
Peru 2
Philippines 1 No. %
NO. % (Specialist) (Specialist)
Singapore 12
Taiwan 23
ICU Type
Thailand 12
Turkey 32 CCU 18 17 94.4 4 (4) 72.2 (22.2)
UAE 1
Qatar 4 Medical 60 57 95.0 40 (4) 66.7 (6.7)
Europe (23) Belgium 4

Surgical 48 43 89.6 29 (5) 60.4 (10.4)
Cyprus Cyprus
Czech Republic 2 Neurologic 23 22 95.7 13 (1) 56.5 (4.3)

Denmark 1
France 2 Paediatric 38 38 100.0 38 (21) 100.0 (55.3)
Germany 2
Emergency 7 6 85.7 6 (1) 85.7 (14.3)
Netherlands 1
Portugal 1 Mixed 26 23 88.5 17 (1) 65.4 (7.7)
Russian Federation 2
Ukraine 4 Total 220 206 93.6 156 (38) 70.9 (17.3)
United Kingdom 2
Hospital
North America
(26)
Canada 4 Type
United States 20 Public 41 41 100.0 30 (4) 73.2 (9.8)
Mexico 2 Private 179 165 92.2 126 (34) 70.4 (19.0)
Oceania (11) Australia 8
New Zealand 3
Hospital
Bed Size
South America Argentina 3
(13) Less than 21 19 90.5 9 (0) 42.9 (0)
500
Brazil 3
Chile 4 501-1000 137 126 92.0 95 (15) 69.3 (10.9)
Colombia 2
More than 62 61 98.4 52 (23) 83.9 (37.1)
Uruguay 1 1001
TOTAL 560
Table 1. submitted Abstracts for WfsiCCM seoul 2015 Table 2. number of iCU specialists According to iCU type, Hospital type and Hospital size
Congress source: national survey conducted by KsCCM in 2009

92
AGENDA
WORLD FEDERATION OF SOCIETIES

OF INTENSIVE AND CRITICAL CARE
MEDICINE
INTERVIEW WITH PROFESSOR JEAN-LOUIS VINCENT, WFSICCM PRESIDENT
A WFSICCM Task Force will develop global What are you looking forward to most at the
Jean-Louis Vincent
Editor-in-Chief guidance on “What is an ICU?” Can you WFSICCM Congress with its theme of “One
ICU Management expand on this? Step Further: The Pursuit of Excellence in
Head Department of There is a lot of heterogeneity in ICU: big ICUs Critical Care"?
Intensive Care combining very sick and somewhat less sick We can improve our systems, with better processes
Erasme Hospital / Free University of
patients; separate intermediate care units; when of care, better communication in the ICU, team
Brussels
Brussels, Belgium is an intermediate care unit no longer considered approach, checklists etc.That is where most progress
jlvincen@ulb.ac.be an ICU? What about intermediate care units, has been made.
which are geographically separate, and managed
for example. by neurosurgeons or cardiologists or How important are international collabora-
gastroenterologists? The Task Force will address tions in advancing intensive care science and
What have been the highlights of your term these issues. practice, and what is an example of how they
of office? have changed clinical practice?
With modern communication means, it is easier What can intensivists in high-income coun- The ICON study has helped to identify some impor-
to interact all over the world, to know each other tries learn from colleagues in resource- tant ways to improve patient management. Just as an
better, and learn from each other. We have started limited countries, and how can they assist? example, the analysis of transfusions has revealed that
the organisation of large trials, inviting the entire It is interesting to imagine how our work would transfusions may be beneficial in the most severely
word to contribute – the ICON study has been a be in austere conditions. Can we develop simple ill – maybe we have become too restrictive with
great success! We have put several task forces in interventions? our transfusion! We are preparing other clinical
place – on triage problems, end-of-life practices, They can assist by providing guidelines applicable trials, perhaps on fever control – these worldwide
definitions of ICUs and the requirements to be in austere conditions. Selling older material has studies must be relatively simple, however.
considered as an ICU specialist. never been very helpful, as maintenance can be
a limiting factor, and there are other problems. What European and world collaborations
WFSICCM’s mission is “to promote the does the WFSICCM engage in?
highest standards of Intensive and Critical The WFSICCM Congress in Seoul will We have regular contact with the World Health
Care Medicine for all mankind, without include a session to support physicians Organization; they have not been much exposed
discrimination.” How does the Federation and nurses from countries with limited to critically ill patients – they have discovered ICUs
implement that in practice? medical resources. What do you hope it and are now happy to discuss with others. We are
We are working on guidelines and recommen- will achieve? also now consulted by the European authorities.
dations – our website is an excellent means of We have the duty to help our colleagues to organise
communication. Our world congress is a good in the absence of sophisticated monitoring and This interview will appear in ICU Manage-
way, and we anticipate the meeting in Seoul will management systems. They have many questions ment’s Summer issue, which has a cover story
be excellent. we need to address. on “Cost-Effectiveness.” Do you think there
is enough understanding in the intensive
care community about what is cost-effective?
The community understands it better and better…
and sometimes too much! We have not been used
to use costly therapies and are reluctant to the idea
of using some – the activated protein C story is
partly related to this. New drugs are costly and ICU
doctors are not prepared for it! Oncologists do
not have the same hesitations! Our interventions
are not so costly especially in relative terms. As an
example we used to say albumin administration
is costly, but it is not so much in relation to all the
WfsiCCM Board Meeting, Budapest, september 2014 other treatments patients receive today.
image credit: WfsiCCM

94
AGENDA
SMACC CHICAGO
Social Media and Critical Care (smacc)’s third meeting takes place in Chicago from 23-26 June.
ICU Management spoke to one of the smacc founders, Dr. Roger Harris, to find out more.
What is the background to smacc? The involvement of delegates starts well before the so that anyone can download the talks. Smacc has
Oliver Flower and I started our website www. meeting. There have already been > 10000 tweets had 750,000 downloads of these talks from all over
intensivecarenetwork.com, and began collabo- carrying the hashtag #smaccUS.There is no lectern the world, many from developing nations.The big
rating with a similar site run by Chris Nickson and (for speakers to rest on), and we discourage Power- barrier is language.While many health professionals
Mike Cadogan www.lifeinthefastlane.com. We Point with complicated statistics etc. that are hard to in developing countries speak English it is not their
began working with similar sites around the world read and distract from what the speaker is saying. first language so this creates challenges.To this end
and the movement FOAMed (Free Open Access Some find it hard to believe that you can give a high we have been looking at getting the talks translated.
Medical education) was born. Many of these sites impact academic presentation on a critical care topic
were growing exponentially with > 50,000 page without showing all the evidence on PowerPoint What innovative presentation methods do
views per day.They shared a common ethos, which – we would argue that the speaker should inspire you use at smacc?
was that the education they produced was posted the audience to think, go away and read the litera- We plan our sessions with key educational objectives
free for anyone to access. Some sites were blogs, ture for themselves and then re-listen to the talk. and then package that education in an inspiring inter-
others podcasts etc. We decided we would like I challenge any conventional speaker to watch the active experience. Sonowars is a great example (see
to come together as a group and hold a physical greats, such as Professor Simon Finfer, at smacc in the video at https://vimeo.com/74193257) and
meeting driven from the websites. Oliver Flower, Chicago and not agree. you will understand.There are some great messages
Chris Nickson and I came up with the idea of smacc in that session (for instance about the movement
(as it represented our website origins and strong Why is social media so important in critical of the myocardial septum in RV failure), which
social media platforms spreading the education). care? were delivered in an unforgettable theatrical style.
We established a Not for Profit (NFP) charity, and Social Media (SoMe) is important to all doctors.
the three of us seeded the meeting from our own We present at many different meetings now as they What are you looking forward to the most
pockets as a donation to the project. We expected all recognise that SoMe is a great way of commu- at smacc Chicago?
100 delegates and got 700 at the first meeting. nicating. It creates a conversation that can be held For me personally – it being over! We all contribute
very rapidly.The journals recognise this, and many hundreds and thousands of hours on this project
The smacc meeting has grown to over 2,500 research studies now use SoMe as one of their means for free. The committee pays their own way…we
delegates. What do you attribute this phenom- for disseminating information. do this because we believe passionately in FOAMed,
enal growth to? but I think we will all be glad for a break in July.That
The meeting is different to anything else out there. Smacc lists many affiliated websites in North said I can’t wait to feel the buzz, the vibrant energy
One delegate wrote to say it was the first meeting she America, Australasia and Europe. Are you that smacc generates – it’s electric and I haven’t
had been to for years (including all the big Austral- hoping that low-income countries will be encountered anything like this in my 20 years of
asian / North American and European meetings) able to participate? attending critical care conferences.
where she came away feeling “inspired, proud to Any website that contributes to FOAM can get
be a doctor and excited to take her knowledge involved. The material from smacc is all podcast For further information visit
back to work”! and released free on the Internet after the conference http://www.smacc.net.au/
Be part of SMACC on Twitter -

Follow:
Roger Harris @RogerRdharris
oliver flower @oliflower
Chris nickson @precordialthump
the sMACC team @smaccteam
and use the following hashtags:
#smaccUs
#foAMed
#foAMcc

AGENDA
ICU Management is the official Management and Practice Journal
of the international symposium on intensive Care and Emergency Medicine
EDITOR-IN CHIEF
Jean-Louis vincent, Consultant, Department of intensive Care,
Erasme Hospital, free University of Brussels, Belgium jlvincen@ulb.ac.be
JUNE EDITORIAL BOARD

Prof. Antonio Artigas (spain) aartigas@cspt.es
23-26 sMACC Chicago Prof. Jan Bakker (the netherlands)
Prof. Richard Beale (United Kingdom)
jan.bakker@erasmusmc.nl
richard.beale@gstt.sthames.nhs.uk
social Media and Critical Care Prof. Rinaldo Bellomo (Australia) Rinaldo.Bellomo@austin.org.au
Chicago, UsA Prof. Jan de Waele (Belgium) Jan.DeWaele@UGent.be
www.smacc.net.au Dr. todd Dorman (United states) tdorman@jhmi.edu
Dr. Bin Du (China) dubin98@gmail.com
24-26 sEsAM 2015 Prof. Hans Kristian flaatten (norway)
Prof. Luciano Gattinoni (italy)
hans.flaatten@helse-bergen.no
gattinon@policlinico.mi.it
Belfast, ireland Prof. Armand Girbes (netherlands) arj.girbes@vumc.nl
www.sesambelfast2015.com Prof. Edgar Jimenez (United states) edgar.jimenez@orlandohealth.com
Prof. John A. Kellum (United states) kellumja@ccm.upmc.edu
JULY Prof. Jeff Lipman (Australia) j.lipman@uq.edu.au
Prof. John Marini (United states) John.J.Marini@HealthPartners.com
8-12 isCCM: 3rd Annual international Best of Brussels symposium Prof. John Marshall (Canada) MarshallJ@smh.ca
on intensive Care and Emergency Medicine Prof. Paul E. Pepe (United states) paul.pepe@utsouthwestern.edu
Prof. Paolo Pelosi (italy) ppelosi@hotmail.com
Pune, india
Dr. shirish Prayag (india) shirishprayag@gmail.com
www.isccmpune.com Prof. Peter Pronovost (United states) ppronovo@jhmi.edu
Prof. Konrad Reinhart (Germany) konrad.reinhart@med.uni-jena.de
16-18 Paediatric Continuous Renal Replacement therapy Prof. Gordon Rubenfeld (Canada) Gordon.Rubenfeld@sunnybrook.ca
London, UK Prof. Eliezer silva (Brazil) silva.eliezer@einstein.br
Prof. Jukka takala (switzerland) jukka.takala@insel.ch
www.pcrrtconferences.com
AUGUST NATIONAL CORRESPONDENTS
nathalie Danjoux (Canada) nathalie.danjoux@uhn.on.ca
14-16 Annual scientific Meeting on intensive Care (AsMiC) Prof. David Edbrooke (United Kingdom)
Prof. Dr. Dominique vandijck (Belgium)
davidedbrooke117@btinternet.com
dominique.vandijck@ugent.be
Kuala Lumpur, Malaysia
www.msic.org.my MANAGING EDITOR
Claire Pillar editorial@icu-management.org
29-1 12th Congress of the World federation of societies of intensive and
September Critical Care Medicine
EDITORS
Carine Khoury ck@healthmanagement.org
seoul, Korea Lucie Robson lr@ healthmanagement.org
www.wfsiccm2015.com Americas Region Editor: samna Ghani sg@healthmanagement.org
APAC Region Editor: Dran Coronado dc@healthmanagement.org

29-2 EsC Congress 2015 Editorial Assistant: Dana Ungureanu office@healthmanagement.org
September London, UK GUEST AUTHORS

www.escardio.org/EsC2015 Massimo Antonelli, Jan Bakker, Alessandro Barelli, Roberta Barelli, David Brealey, Peter
Brindley, Jayna Gardner-Gray, Antonio Gullì, Barbara Gutenbrunner, Roger Harris, Christian J.
Herold, Gina Hurst, Dong Chan Kim, Claus Krenn, Diana Lebherz-Eichinger, sang-Min Lee, Diku
SEPTEMBER Mandavia, sungwon na, Maarten W.n. nijsten, Paul Pepe, Jacqueline Pflaum-Carlson, Albert
Reiter, Emanuel P. Rivers, Georg A. Roth, Jean-Louis vincent, Heidi Wimmers
5-8 EsPEn
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02

COVER STORY: Cost-EffECtivEnEss

ICU Management 2 - 2015

Moving From “Learning By Doing” To Partnering Medicine and Public Service

ICU Management 2 - 2015

Dr. Todd Dorman

Study Provides Guidance for ICU Staffing

ICU Management 2 - 2015

Reducing the Risk of Recurrence of C. Diff Infection

Sign up for ICU Management Highlights

Simply visit www.icu-management.org

OMITTING ROUTINE CHEST RADIO-

ICU Management 2 - 2015

“Restrictions may help to decrease costs, reduce radia- Patient subgroups

Medical (n) 30* 50 56

Thoracic surgery (n) 12 11

ICU Management 2 - 2015

bution to diagnosis, economic aspects, and patients’ Discussion

detect cardiopulmonary complications in

ICU Management 2 - 2015

ICU Management 2 - 2015

ICU Management 2 - 2015

about 37,000 patients and contributing an addi-

ICU Management 2 - 2015

instead of working blindly.

ICU Management 2 - 2015

Maarten W. Nijsten, MD,

ICU Management 2 - 2015

glucose-control are combined with lactate and

ICU Management 2 - 2015

ICU Management 2 - 2015

EARLY SEPSIS MANAGEMENT

sepsis. We will discuss these treatments in the Source Control

Department of Emergency Medicine

T he tenets of early sepsis management

ICU Management 2 - 2015

The Pathobiology of Haemodynamic Optimisation

Sepsis is a result of severe haemodynamic triggers that ultimately result in

Preload Optimisation or Intravenous Fluids

Preload Measurement (Central Venous Pressure or Other

Thus the focus during the first hour should be

Central Venous Oxygenation

involve fluid resuscitation, inotropic administration,

ICU Management 2 - 2015

up to 40% of oxygen consumption in sepsis and animal studies

2,254 2,226 2,083

a fluid challenge, antibiotics, source control and early ICU

ICU Management 2 - 2015

RAPID PATHOGEN TESTING WITH

ICU Management 2 - 2015

WHY IS DRUG TRACEABILITY

I n our globalised economy, the risks of

ICU Management 2 - 2015

ICU Management 2 - 2015

MOVING FROM “LEARNING

reality. Poor communication has been identified a mannequin-based simulator to systematically

to anaesthesia and intensive care training are (Reader et al. 2006).

H istorically, medical education has

ICU Management 2 - 2015

ICU Management 2 - 2015

ICU Management 2 - 2015

ICU Management 2 - 2015

ICU Management 2 - 2015

ICU Management 2 - 2015