American College of Physicians: Internal Medicine — Doctors for Adults ®


Critical care course addresses acute disease management strategies

By Rochelle Nataloni

The intensive care unit sees it all—from acute renal failure to drug overdoses, from sepsis to acute respiratory distress syndrome and everything in between. The Critical Care 2007 pre-course held earlier this week held critical care practices under the microscope with an intensive look at a number of common illnesses and issues associated with critical care medicine.

"We're in a changing environment where new information emerges all the time," said course director Robert A. Balk, FACP, of Rush University Medical Center in Chicago. During the two-day course, Dr. Balk and the course faculty discussed a number of topics:

  • Dr. Michael Niederman, chairman of medicine at Winthrop Univeristy Hospital in Mineola, N.Y., discussed how to approach the patient with severe pneumonia and how to diagnose, treat and prevent pneumonia in the ICU patient. He emphasized the importance of starting effective appropriate antibiotic therapy as soon as possible to achieve the best patient outcomes. Guidelines have been established by the Infectious Diseases Society of America and the American Thoracic Society to guide the choice of antibiotics and other management decisions. Dr. Curtis Sessler from Virginia Commonwealth University System and Medical College of Virginia in Richmond, Va., reviewed the latest information concerning the approach to the septic patient. Again, the emphasis was on timely diagnosis and the early administration of effective therapy. He discussed the use of "bundles of care" to assure that patients receive the best possible management in the most efficient and timely fashion. Dr. Balk of Rush University Medical Center in Chicago discussed the diagnosis and management of acute lung injury and the acute respiratory distress syndrome (ARDS). He emphasized strategies to maintain and improve oxygenation status in these critically ill patients. He also discussed current recommendations regarding the use of corticosteroids for non-resolving ARDS.

  • Managing acute coronary syndromes was discussed with emphasis on the fact that heart disease is the number-one cause of death in the United States. "It's important to proceed to intervention as soon as possible, with continued emphasis on getting those people who present acutely with chest pain and EKG changes into the cardiac catheterization lab as early as possible," said Dr. Steven Hollenberg of Cooper University Hospital in Camden, N.J. Dr. R. Phillip Dellinger, also of Cooper Hospital, discussed ventilator management strategies for the critically ill patient. His presentation was complemented by a discussion of noninvasive positive-pressure ventilation given by Dr. Janice Zimmerman of Baylor College of Medicine in Houston. Noninvasive ventilation is being used with greater frequency in critically ill patients, particularly those with a COPD exacerbation or cardiogenic pulmonary edema, and it is imperative for practitioners to be knowledgeable about its proper indication and application.

  • Dr. Cherylee Chang, an associate clinical professor of medicine at the University of Hawaii, discussed the approach to acute stroke management. She emphasized the importance of timely recognition and treatment. She also reviewed the use of thrombolytic therapy in the setting of acute stroke as well as the role for anticoagulation therapy in the at-risk and post-stroke population of patients. In addition, Dr. Chang presented a diagnostic approach for patients with altered mental status and/or coma. She emphasized the wide range of differential diagnoses and the importance of a thorough investigation as to the etiology of the mental status changes.

  • Dr. Ravindra Mehta of the University of California, San Diego, School of Medicine discussed the causes of acute renal failure and the indications for renal replacement therapy. He reviewed the results of strategies to provide more intense dialysis to the critically ill patient with renal failure in contrast to the more standard intermittent dialysis.

  • Patient safety. To combat the increasing prevalence of antimicrobial resistance in the ICU, a more judicious approach to the use of antibiotics is required. Antibiotic stewardship and the causes and management of fever in the critically ill patient were addressed by Dr. George Karam, a professor of medicine at LSU School of Medicine and an infectious disease expert.

  • Dr. David Gurka of Rush University Medical Center in Chicago discussed common-sense approaches to avoiding complications in the ICU. "Simply paying attention to good infection control practice, such as proper skin preparation, use of appropriate draping, wearing gloves and proper insertion technique will decrease the risk of line infections," he said. He added that even the simple maneuver of keeping the head of the bed at 30 degrees can decrease the risk of developing hospital-acquired pneumonia.

    Both the Institute for Healthcare Improvement and the Institute of Medicine have emphasized the fact that far too many errors take place each year in hospitalized patients. These errors result in almost 100,000 deaths per year in the U.S., and it is crucial that we look at our critical care practices and adopt strategies to minimize the risk to this population of patients, who are even more vulnerable because of their underlying medical illnesses. Prophylactic strategies to prevent stress-related mucosal bleeding, nosocomial infections and venous thromboembolic diseases will decrease the development of these complications and result in improved outcome along with decreased length of stay. Dr. Dellinger reviewed the latest studies on diagnosis and management of pulmonary embolism with emphasis on the role of D-dimer testing and chest CT with PE protocol to assist with the diagnosis.

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