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We report a case of a 62-year-old woman with a decade-long history of atypical chest pain resulting in a largely negative cardiac workup, who developed significant angiographically demonstrated coronary vasospasm thought to be due to a small dose of intravenous ketamine. In patients with a history of atypical chest pain despite a reassuring cardiac evaluation, providers should carefully consider medications that may precipitate coronary vasospasm and be prepared to treat it accordingly., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Rationale: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care facilities have implemented systems aimed at detecting and responding to such patients., Objectives: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients., Panel Design: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based clinical practice guidelines., Methods: We generated actionable questions using the Population, Intervention, Control, and Outcomes format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs)., Results: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among "unselected" patients due to the absence of data regarding the benefit and the potential harms of false positive alarms, the risk of alarm fatigue, and cost. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system (GPS)., Conclusions: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU., Competing Interests: Panel members disclosed all potential financial and intellectual conflicts of interest according to the American College of Critical Care Medicine/Society of Critical Care Medicine Standard Operating Procedures. For details, please refer to Supplemental Digital Contents 1 and 2 (http://links.lww.com/CCM/H433). Dr. Penoyer received funding from Ivenix, Avanos, ICU Medical, and BD. Dr. Davis disclosed he is a consultant for Zoll and Healthstream and is Chief Executive Officer of Medical X Technologies. Dr. Edelson disclosed that she is president and co-founder of AgileMD and received equity interest, she is an employee of the National Institutes of Health, and she received a research grant from BARDA (ARCD.P0535US). Dr. Rowley received funding from Draeger, STIMIT, and Vyaire. Dr. DeVita disclosed that he is a consultant for Hill Rom. Dr. Welch disclosed that he is an advisor in a one-off Becton, Dickinson and Co. Adult and Specialist Critical Care Advisory Board. Dr. Kellett disclosed that he is the founder and major shareholder of Tapa Healthcare DAC. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Rationale: Clinical deterioration of patients hospitalized outside the ICU is a source of potentially reversible morbidity and mortality. To address this, some acute care hospitals have implemented systems aimed at detecting and responding to such patients., Objectives: To provide evidence-based recommendations for hospital clinicians and administrators to optimize recognition and response to clinical deterioration in non-ICU patients., Panel Design: The 25-member panel included representatives from medicine, nursing, respiratory therapy, pharmacy, patient/family partners, and clinician-methodologists with expertise in developing evidence-based Clinical Practice Guidelines., Methods: We generated actionable questions using the Population, Intervention, Control, and Outcomes (PICO) format and performed a systematic review of the literature to identify and synthesize the best available evidence. We used the Grading of Recommendations Assessment, Development, and Evaluation Approach to determine certainty in the evidence and to formulate recommendations and good practice statements (GPSs)., Results: The panel issued 10 statements on recognizing and responding to non-ICU patients with critical illness. Healthcare personnel and institutions should ensure that all vital sign acquisition is timely and accurate (GPS). We make no recommendation on the use of continuous vital sign monitoring among unselected patients. We suggest focused education for bedside clinicians in signs of clinical deterioration, and we also suggest that patient/family/care partners' concerns be included in decisions to obtain additional opinions and help (both conditional recommendations). We recommend hospital-wide deployment of a rapid response team or medical emergency team (RRT/MET) with explicit activation criteria (strong recommendation). We make no recommendation about RRT/MET professional composition or inclusion of palliative care members on the responding team but suggest that the skill set of responders should include eliciting patients' goals of care (conditional recommendation). Finally, quality improvement processes should be part of a rapid response system., Conclusions: The panel provided guidance to inform clinicians and administrators on effective processes to improve the care of patients at-risk for developing critical illness outside the ICU., Competing Interests: Funding for these guidelines was provided solely by the Society of Critical Care Medicine. Panel members disclosed all potential financial and intellectual conflicts of interest according to the American College of Critical Care Medicine/Society of Critical Care Medicine Standard Operating Procedures. Refer to Supplemental Digital Contents 1 and 2 (http://links.lww.com/CCM/H434) for details. Dr. Penoyer received funding from Ivenix, Inc, Avanos, ICU Medical, and BD. Dr. Davis disclosed he is a consultant for Zoll and Healthstream and is Chief Executive Officer of Medical X Technologies. Dr. Edelson disclosed that she is president and co-founder of AgileMD and received equity interest, she is an employee of the National Institutes of Health, and received a research grant from BARDA (ARCD.P0535US). Dr. Rowley received funding from Draeger, STIMIT, and Vyaire. Dr. DeVita disclosed that he is a consultant for Hill Rom. Dr. Welch disclosed that he is an advisor in a one-off Becton, Dickinson and Co. Adult and Specialist Critical Care Advisory Board. Dr. Kellett disclosed that he is the founder and major shareholder of Tapa Healthcare DAC. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: Emergency intubations are commonly associated with adverse events when performed in critically ill patients. A detailed look at intubation factors and their association with procedural success and mortality has yet to be fully conducted., Methods: A total of 299 successive intubations at a tertiary Veteran Affair hospital were analyzed. Situational factors, personnel involved, intubation indications, induction agents, and airway management techniques were prospectively collected and entered into univariable and multivariable analyses to identify factors associated with procedural difficulty and mortality., Results: The use of paralytics was associated with easier intubations (OR: 0.31, 95% CI: 0.11-0.87, p = .03). The use of direct laryngoscopy or video laryngoscopy had no significant association with difficult intubation. Factors associated with increased 30-day mortality were cardiac arrest (OR: 7.90, 95% CI: 2.77-22.50, p < .001), hypoxia as indication for intubation (OR: 2.31, 95% CI: 1.23-4.35, p = .009), and nadir SpO 2  < 90% (OR: 2.70, 95% CI: 1.01-7.21, p = .048). Presence of an attending anesthesiologist during intubation was associated with a lower 30-day mortality (OR: 0.11, 95% CI: 0.04-0.29, p < .001). Factors associated with increased 90-day mortality were cardiac arrest (OR: 6.57, 95% CI: 2.23-19.34, p = .001), hypoxia as indication for intubation (OR: 1.97, 95% CI: 1.10-3.55, p = .023), and older age (OR: 1.38, 95% CI: 1.07-1.78, p = .013). Similarly, presence of an attending anesthesiologist was found to be associated with a lower 90-day mortality (OR: 0.19, 95% CI: 0.07-0.50, p = .001)., Conclusion: Cardiovascular and respiratory instability were associated with increased 30- and 90-day mortality. Presence of an attending anesthesiologist was associated with a better survival following intubation outside operating room., (© 2023 Acta Anaesthesiologica Scandinavica Foundation.)

Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Gupta et al.)

Objectives: Physiological decompensation of hospitalized patients is common and is associated with substantial morbidity and mortality. Research surrounding patient decompensation has been hampered by the absence of a robust definition of decompensation and lack of standardized clinical criteria with which to identify patients who have decompensated. We aimed to: 1) develop a consensus definition of physiological decompensation and 2) to develop clinical criteria to identify patients who have decompensated., Design: We utilized a three-phase, modified electronic Delphi (eDelphi) process, followed by a discussion round to generate consensus on the definition of physiological decompensation and on criteria to identify decompensation. We then validated the criteria using a retrospective cohort study of adult patients admitted to the Hospital of the University of Pennsylvania., Setting: Quaternary academic medical center., Patients: Adult patients admitted to the Hospital of the University of Pennsylvania who had triggered a rapid response team (RRT) response between January 1, 2019, and December 31, 2020., Interventions: None., Measurements and Main Results: Sixty-nine experts participated in the eDelphi. Participation was high across the three survey rounds (first round: 93%, second round: 94%, and third round: 98%). The expert panel arrived at a consensus definition of physiological decompensation, "An acute worsening of a patient's clinical status that poses a substantial increase to an individual's short-term risk of death or serious harm." Consensus was also reached on criteria for physiological decompensation. Invasive mechanical ventilation, severe hypoxemia, and use of vasopressor or inotrope medication were bundled as criteria for our novel decompensation metric: the adult inpatient decompensation event (AIDE). Patients who met greater than one AIDE criteria within 24 hours of an RRT call had increased adjusted odds of 7-day mortality (adjusted odds ratio [aOR], 4.1 [95% CI, 2.5-6.7]) and intensive care unit transfer (aOR, 20.6 [95% CI, 14.2-30.0])., Conclusions: Through the eDelphi process, we have reached a consensus definition of physiological decompensation and proposed clinical criteria with which to identify patients who have decompensated using data easily available from the electronic medical record, the AIDE criteria., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: To measure the relationship between lactate and mortality in hospital inpatients. Main outcomes of interest were 3-day, 30-day, and 1-year all-cause mortality., Design: Retrospective cohort study, October 2011 to September 2013., Setting: University-affiliated US Veterans Affairs Hospital., Patients: All inpatients with lactate level measured during the study period., Measurements: Analysis of peak lactate level (mmol/L) during the most recent admission for patients who died, and peak lactate level during an admission for surviving patients. Covariates including sepsis, ICU admission, code blue and rapid response calls, medical vs surgical ward, liver disease, kidney disease, and hospice status were recorded., Results: In total, 3325 inpatients were included; 564 patients had sepsis. Median lactate 1.7 mmol/L (interquartile range [IQR] 1.2-2.6). The 3-day, 30-day, and 1-year mortality were 2.5%, 10%, and 24%, respectively. A lactate level cutoff of ⩾4 mmol/L had best test characteristics (sensitivity 52.4%, specificity 91.4%) to predict increased 3-day mortality. Unadjusted risk ratio of death in 3 days for lactate ⩾4 was 10.3 (95% confidence interval [CI] 6.8-15.7). Patients with sepsis had a consistently higher risk of death compared with patients without sepsis for any given level of lactate. Adjusted odds ratio (OR) of 3-day mortality for lactate ⩾4 was 7.6 (95% CI 4.6-12.5); 30-day mortality was 2.6 (95% CI 1.9-3.6); and 1-year mortality was 1.8 (95% CI 1.4-2.6). Lactates in the normal range (<1.7) were also independently associated with 30-day and 1-year mortality., Conclusions: Lactate predicts risk of death in all patients, although patients with sepsis have a higher mortality for any given lactate level. We report the novel finding that serum lactate, including normal values, is associated with long-term mortality., Competing Interests: Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A higher mortality trend correlated with increased age and length of stay for medical and surgical patients in the intensive care unit., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

In this case, we report difficulty in the conduct of carotid surgery during an earthquake. With the epicenter >200 miles away, intraoperative movement was subtle and initially attributed to recovery from neuromuscular blockade. More significant seismic motion in a hospital is accompanied by additional challenges that are discussed.

In the United States, more than 100,000 tracheostomies are performed annually. Many patients undergoing tracheostomy are critically ill, making them higher risk surgical candidates. Fortunately, the loss of airway during the procedure is rare, but when it occurs, the outcome can be catastrophic. In this report, we describe a technique to minimize the risk of airway loss by using an airway exchange catheter as an airway conduit during endotracheal tube removal. We present 2 clinical cases in which this technique was used successfully and made an important contribution to patient safety.

This video demonstrates the placement of a laryngeal mask airway, an alternative airway device that is both efficacious and easy to place. The laryngeal mask airway is routinely used for patients receiving general anesthesia and, increasingly, in patient resuscitation.

Shock states are defined by stereotypic changes in well-known physiologic parameters. While these well-known changes provide a convenient entry point into further evaluation of patients in shock or at risk for shock, use of such physiologic evaluation is not commonly seen in clinical medicine. A formal description of physiologic reasoning in the diagnosis of shock states is presented in this paper. Included with this conceptual framework is a discussion of key tests or findings that can be used to differentiate between possible diagnoses, and the pairing of treatment strategies to distinct classes of physiologic abnormalities. It is hoped that the methodology presented here will demonstrate the primacy of physiologic reasoning in the diagnosis and treatment of hemodynamic instability. Advantages of this method are speed and accuracy, efficient use of resources, and mitigation against sources of medical errors.

Accurate assessments of intravascular fluid status are an essential part of perioperative care and necessary in the management of the hemodynamically unstable patient. Goal-directed fluid management can facilitate resuscitation of the hypovolemic patient, reduce the risk of fluid overload, reduce the risk of the injudicious use of vasopressors and inotropes, and improve clinical outcomes. In this paper, we discuss the strengths and limitations of a spectrum of noninvasive and invasive techniques for assessing and monitoring intravascular volume status and fluid responsiveness in the perioperative and critically ill patient.

The cross-disciplinary nature of patient care and medical emergency teams allows for identification of systemwide problems that might otherwise be perceived as isolated events.

Heme oxygenase type 2 (HO-2) is an enzyme that uses heme as a substrate to produce iron, biliverdin, and carbon monoxide (CO). This enzyme participates in regulation of nociceptive signal transmission in spinal cord tissue. We set out to identify genes undergoing alterations in expression in a model of inflammatory pain and to determine whether HO-2 participates in that regulation. After the hindpaw injection of formalin in mice, we measured changes in expression of immediate early genes including c-fos, c-jun, jun B, nerve growth factor induced genes (NGFI-A and NGFI-B) and activity-related cytoskeletal protein (ARC) using real-time PCR. The mRNA corresponding to these genes increased in abundance in the first hour after formalin injection and then slowly declined. Changes in the abundance of prodynorphin, extracellular signal related kinases (ERK1 and ERK2) and N-methyl-D-aspartate (NMDA) receptor R1 subunit mRNA generally peaked between 8 and 12 hr after formalin injection. In HO-2 null mutant mice, the enhancement of expression was less for all genes studied. We went on to quantify gene expression in superficial dorsal horn tissue using laser capture microdissection followed by RNA amplification and real-time PCR. The results confirmed that the changes in gene expression were occurring in regions of the spinal cord involved in nociceptive processing. We conclude that the hindpaw injection of formalin leads to enhanced early and late expression of many genes in spinal cord dorsal horn tissue, and that this enhancement of expression relies to a degree on the presence of HO-2.

A patient with the genetic condition neurofibromatosis type I and no known coagulopathy undergoing cesarean delivery, had diffuse uterine and surgical site bleeding that was not correctable by oxytocin, methylergonovine and PGF2 alpha. Despite good uterine tone, hemorrhage continued from the uterus and the surrounding tissues, persisting even after surgical ligation of the uterine arteries. With no change in her condition, which was behaving clinically as a coagulopathy, an infusion of desmopressin acetate (DDAVP) was begun. The patient's bleeding promptly resolved shortly after infusion of this agent. A review of relevant literature suggests that platelet reactivity of patients with neurofibromatosis type 1 is attenuated in some in vitro conditions. Thus, there may be some theoretical basis for using DDAVP in patients with neurofibromatosis type 1 who have bleeding problems with no other known source, such as in the case presented here.

Intense vagal discharge often follows stimulus application during electroconvulsive therapy (ECT). Related periods of asystole during ECT have been reported sporadically in psychiatric journals, but to date not in the anesthesia literature. We report here two cases of prolonged asystole that occurred in our facility in spite of the fact that published suggestions for its prevention were followed. With careful monitoring of these patients--including echocardiography for one patient--we document the onset of asystole at the exact time of ECT stimulus application. With these data, we discuss why asystole is likely to result from a direct central pathway rather than via a baroreceptor reflex, and discuss a neuroanatomic pathway potentially responsible for our findings. We also demonstrate that high-dose atropine (0.8 mg) can effectively prevent most cases of asystole in susceptible patients, and that administration of esmolol following cessation of seizures effectively reduces the elevated heart rate without causing asystole or bradycardia.

Unlabelled: Hyperalgesia occurring after the cessation of chronic opioid administration occurs in humans and has been modeled in rodents with chronic systemic and intrathecal administration paradigms. It is, however, unclear if this type of postanalgesic hyperalgesia is unique to opioids. The alpha(2)-adrenergic receptor agonist, dexmedetomidine (Dex), is similar to opioids in that it is an analgesic that interacts with cell-surface receptors linked to the inhibition of adenylate cyclase and the modulation of ion channel activity. In these studies, we first constructed antinociceptive dose-response curves for Dex and morphine (MSO4). The 50% effective doses for Dex and MSO4 administered intraperitoneally to C57Bl/6 mice were 75 micro g/kg and 5.2 mg/kg, respectively. Using equally effective doses, we treated separate groups of mice with twice-daily injections of Dex or MSO4 for 5 days. Tolerance to these drugs was documented after this period. In the 16-72 h after cessation of administration, MSO4-treated mice demonstrated both thermal hyperalgesia and mechanical allodynia. However, the Dex-treated mice showed no changes in their thermal or mechanical withdrawal thresholds. We conclude that using this experimental paradigm, opioids but not an alpha(2)-adrenergic agonist, cause hyperalgesia and allodynia after cessation of chronic administration., Implications: The cessation of the administration of opioids is associated with hyperalgesia in both humans and other animals. However, antinociceptive dexmedetomidine does not seem to be associated with this type of hyperalgesia syndrome during periods of abstinence.

Study Objective: To determine the onset and clinical duration of cisatracurium and rocuronium in equipotent doses in balanced opioid/isoflurane anesthesia., Design: Randomized, controlled study., Setting: University hospital., Patients: 40 healthy patients scheduled for elective surgery., Interventions: Patients underwent anesthesia induction with thiopental or propofol with a cisatracurium intubating dose of either 0.15 or 0.2 mg/kg or a rocuronium dose of either 0.9 or 1.2 mg/kg. These doses correspond to three and four times the ED95 dose., Measurements and Main Results: The onset time and time to 25% recovery of baseline first twitch in a train-of-four were determined using an accelerometric sensor. Rocuronium had a faster onset time that cisatracurium at equipotent doses (3 x ED95: 134 vs. 220 sec respectively, and at 4 x ED95: 95 vs. 162 sec). Recovery tended to be faster, but not statistically different for cisatracurium compared to rocuronium., Conclusions: With equipotent intubating doses of rocuronium and cisatracurium, rocuronium produces a more rapid onset of muscle relaxation. The data suggest a tendency toward more rapid clinical recovery of cisatracurium compared to equipotent doses of rocuronium, although these differences were not statistically significant.

Chromosome size polymorphisms occur in Leishmania such that each strain of a given species has a distinctive molecular karyotype. Despite this variability, the chromosomal similarities among closely related strains of Leishmania are sufficiently characteristic to permit classification of unidentified clinical isolates. Mechanisms generating chromosome size polymorphisms are related to chromosomal evolution. In this review, Geoffrey Lighthall and Suzanne Giannini explain that the chromosomal profiles of members of different species may be diverging from a conserved 'consensus' karyotype at different rates, and present a current understanding of the genomic organization of Leishmania with emphasis on chromosomal elements.