Mind the Gap: Wearable Lactate and Glucose Monitors for Hospitalized Patients.

Continuous and non-invasive monitoring of metabolic parameters, particularly glucose and lactate, represents a critical advance in inpatient medicine where current technologies fall short. Wearable sensors are widely available for glucose, and are commonly and successfully used in ambulatory settings. More recently, wearable sensors have become available for lactate, and these devices have a proven role in exercise physiology literature.

Serial Lactate in Clinical Medicine - A Narrative Review.

BackgroundBlood lactate is commonly used in clinical medicine as a diagnostic, therapeutic and prognostic guide. Lactate's growing importance in many disciplines of clinical medicine and academic enquiry is underscored by the tenfold increase in publications over the past 10 years. Lactate monitoring is presently shifting from single to serial measurements, offering a means of assessing response to therapy and to guide treatment decisions.

The risks of long-term use of proton pump inhibitors: a critical review.

Proton pump inhibitors (PPIs) are among the most frequently prescribed medications. Their use is likely even higher than estimated due to an increase in the number of PPIs available without a prescription. Appropriate indications for PPI use include infection, erosive esophagitis, gastric ulcers, and stress ulcer prevention in high-risk critically ill patients.

Balanced Crystalloids versus Saline in Critically Ill Adults.

Background: Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes.

Methods: In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted.

The State of Neurocritical Care Fellowship Training and Attitudes toward Accreditation and Certification: A Survey of Neurocritical Care Fellowship Program Directors.

Neurocritical care as a recognized and distinct subspecialty of critical care has grown remarkably since its inception in the 1980s. As of 2016, there were 61 fellowship training programs accredited by the United Council for Neurologic Subspecialties (UCNS) in the United States and more than 1,000 UCNS-certified neurointensivists from diverse medical backgrounds. In late 2015, the Program Accreditation, Physician Certification, and Fellowship Training (PACT) Committee of the Neurocritical Care Society (NCS) was convened to promote and support excellence in the training and certification of neurointensivists.

A Novel Method of Evaluating Key Factors for Success in a Multifaceted Critical Care Fellowship Using Data Envelopment Analysis.

Background: The current system of summative multi-rater evaluations and standardized tests to determine readiness to graduate from critical care fellowships has limitations. We sought to pilot the use of data envelopment analysis (DEA) to assess what aspects of the fellowship program contribute the most to an individual fellow's success. DEA is a nonparametric, operations research technique that uses linear programming to determine the technical efficiency of an entity based on its relative usage of resources in producing the outcome.

ECMO in major burn patients: feasibility and considerations when multiple modes of mechanical ventilation fail.

Background: We report two cases of acute respiratory distress syndrome in burn patients who were successfully managed with good outcomes with extra corporeal membrane oxygenation (ECMO) after failing multiple conventional modes of ventilation, and review the relevant literature.

Case Presentation: The two patients were a 39-year-old male and 53-year-old male with modified Baux Scores of 79 and 78, respectively, with no known inhalation injury. After the initial modified Parkland-based fluid resuscitation and partial escharotomy, both patients developed worsening hypoxemia and acute respiratory distress syndrome.

Balanced crystalloids versus saline in the intensive care unit: study protocol for a cluster-randomized, multiple-crossover trial.

Background: Saline, the intravenous fluid most commonly administered to critically ill adults, contains a high chloride content, which may be associated with acute kidney injury and death. Whether using balanced crystalloids rather than saline decreases the risk of acute kidney injury and death among critically ill adults remains unknown.

Methods: The Isotonic Solutions and Major Adverse Renal Events Trial (SMART) is a pragmatic, cluster-level allocation, cluster-level crossover trial being conducted between 1 June 2015 and 30 April 2017 in five intensive care units at Vanderbilt University Medical Center in Nashville, TN, USA.

Tension pneumomediastnum: A rare cause of acute intraoperative circulatory collapse in the setting of unremarkable TEE findings.

Design: Case report.

Setting: Operating room.

Patient: 25YF, ASA IV E who underwent an emergent decompressive craniectomy for refractory intracranial hypertension secondary to acute intracranial hemorhage.

Fluid resuscitation mediates the association between inhalational burn injury and acute kidney injury in the major burn population.

Background: It is known that acute respiratory distress syndrome and acute lung injury are independent risk factors for developing acute kidney injury (AKI) through complex pathophysiologic mechanisms. Our specific aim is to evaluate the risk factors for AKI postburn injury and whether inhalation thermal injury is an independent risk factor for developing AKI in the major burn population.

Methods: This is an institutional review board-approved, retrospective cohort study of patients admitted to a tertiary burn intensive care unit between 2011 and 2013.

A Secure, Social Media-Based "Case of the Month" Module in a Neurocritical Care Unit.

Background: Systems to meet the on-demand learning needs of nurses in intensive care units are not well studied beyond the traditional classroom models.

Objective: To study the feasibility and effect of implementing an online discussion forum for nurses in a busy neuroscience intensive care unit.

Methods: A baseline survey was done to highlight the areas of educational need in the unit.

Heparin Resistance and Anticoagulation Failure in a Challenging Case of Cerebral Venous Sinus Thrombosis.

We report a challenging case of cerebral venous sinus thrombosis (multiple etiologic factors) that was complicated by heparin resistance secondary to suspected antithrombin III (ATIII) deficiency. A 20-year-old female previously healthy and currently 8 weeks pregnant presented with worsening headaches, nausea, and decreasing Glasgow Coma Scale/Score (GCS), necessitating mechanical ventilatory support. Imaging showed extensive clots in multiple cerebral venous sinuses including the superior sagittal sinus, transverse, sigmoid, jugular veins, and the straight sinus.

Identification of Major Adverse Kidney Events Within the Electronic Health Record.

Acute kidney injury is common among critically ill adults and is associated with increased mortality and morbidity. The Major Adverse Kidney Events by 30 days (MAKE30) composite of death, new renal replacement therapy, or persistent renal dysfunction is recommended as a patient-centered outcome for pragmatic trials involving acute kidney injury. Accurate electronic detection of the MAKE30 endpoint using data within the electronic health record (EHR) could facilitate the use of the EHR in large-scale kidney injury research.

Profound Autonomic Instability Complicated by Multiple Episodes of Cardiac Asystole and Refractory Bradycardia in a Patient with Anti-NMDA Encephalitis.

Anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) is autoimmune encephalitis primarily affecting young adults and children. First described about a decade ago, it frequently manifests as a syndrome that includes progressive behavioral changes, psychosis, central hypoventilation, seizures, and autonomic instability. Although cardiac arrhythmias often accompany anti-NMDARE, the need for long-term electrophysiological support is rare.

Hypernatremia is a significant risk factor for acute kidney injury after subarachnoid hemorrhage: a retrospective analysis.

Background: Hypertonic saline therapy is often used in critically ill subarachnoid hemorrhage (SAH) patients for indications ranging from control of intracranial hypertension to managing symptomatic hyponatremia. The risk factors for developing acute kidney injury (AKI) in this patient population are not well defined.

Specific Aim: To study the role of serum sodium in developing AKI (based on the AKIN definition) in the SAH population admitted to a large academic neurocritical care unit.

Rapidly Progressing Severe Cutaneous Adverse Reaction With Acute Kidney Injury After Drug Exposure: An Uncommon Presentation.

Toxic epidermal necrolysis syndrome (TEN) is a rare severe cutaneous adverse drug reaction that involves skin and mucous membranes. We describe a case of TEN presenting with stage III acute kidney injury, rhabdomyolysis, and acute respiratory failure likely triggered by allopurinol for recently diagnosed gout. Prompt diagnosis, multidisciplinary management, including aggressive resuscitation, cardiorespiratory support, intravenous immunoglobulin therapy, and daily wound care resulted in a positive outcome despite a predicted mortality greater than 60%.

Obesity and perioperative acute kidney injury: a focused review.

Obesity has reached epidemic proportions in the developed world today. Obesity is a significant risk factor for cardiovascular disease, hypertension, diabetes mellitus, and chronic kidney disease. There has been renewed interest in the role of perioperative renal dysfunction with the establishment of new diagnostic criteria for kidney dysfunction such as the Acute Kidney Injury Network criteria and the Risk-Injury-Failure-Loss End-stage kidney disease criteria.

How we created a targeted teaching tool using blog architecture for anesthesia and critical care education--the A/e anesthesia exchange blog.

Background: The time constraints on a clinical educator have increased immensely over the past decade. Technology has served to significantly bridge the challenge over the past decade. WHAT WE DID: We created a method of delivering targeted educational content for point of care learning in anesthesia and critical care.

Obesity and post-cardiopulmonary bypass-associated acute kidney injury: a single-center retrospective analysis.

Objective: The authors specifically explored the association of obesity (based on body mass index [BMI]) and the risk of developing acute kidney injury after cardiopulmonary bypass (AKICPB).

Design: Single-center retrospective study.

Setting: Academic medical center.

The effect of the pressure-volume curve for positive end-expiratory pressure titration on clinical outcomes in acute respiratory distress syndrome: a systematic review.

Purpose: Methods to optimize positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) remain controversial despite decades of research. The pressure-volume curve (PVC), a graphical ventilator relationship, has been proposed for prescription of PEEP in ARDS. Whether the use of PVC's improves survival remains unclear.

Stress cardiomyopathy with an "inverse" takotsubo pattern in a patient with acute aneurysmal subarachnoid hemorrhage.

Background: Subarachnoid hemorrhage (SAH) induced myocardial dysfunction (often labeled neurogenic stunned myocardium) encompasses a spectrum of clinical presentations ranging from an isolated elevation of cardiac enzymes to cardiogenic shock.

Objective: We describe a case of stress cardiomyopathy in a patient following acute aneurysmal subarachnoid hemorrhage that showed an "inverse" or reverse takotsubo pattern on echocardiography.

Case Report: The patient was a 46-year-old female who presented with acute cardiogenic shock following acute subarachnoid hemorrhage necessitating aggressive cardiorespiratory in the ICU.

Secondary oxalosis induced acute kidney injury in allograft kidneys.

Secondary oxalosis causing acute kidney injury (AKI) has been widely reported in native kidneys but its occurrence in allograft kidneys is relatively uncommon. We present three patients with acute kidney allograft dysfunction secondary to tubular oxalate microcrystal deposits confirmed on allograft biopsy in the setting of acute gastrointestinal dysfunction. These three patients presented with AKI that was preceded by episodes of ongoing diarrhea ranging from 10 to 90 days.