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Introduction: This case of Loperamide misuse had refractory ventricular arrhythmias and was successfully supported by VA ECMO. Loperamide is currently available without prescription and can be obtained in large quantities over the internet despite Food and Drug Administration (FDA) 2016 black box warning noting cardiac toxicity. This case illustrates the life-threatening toxicity of loperamide and suggests a supportive modality to provide clinical time while the drug is cleared endogenously or exogenously. Case report: A 36-year-old female was found minimally responsive. Vital signs and monitoring revealed wide complex bradycardia, undetectable blood pressure, hypothermia, bradypnea, and hypoglycemia. The rhythm degenerated to polymorphic ventricular tachycardia cardia refractory to multiple ACLS protocols. VA-ECMO was initiated with immediate stabilization. Subsequent history revealed massive consumption of loperamide taking 400-600 mg daily. Highest known loperamide and N-desmethyl-loperamide levels were 32 and 500 ng/ml respectively. Since loperamide and metabolites are known to be protein bound, molecular adsorbent recirculating system (MARS) was initiated for toxin clearance. Additionally, she developed acute renal failure supported by CRRT. She was ultimately weaned from ECMO, MARS, and CRRT and discharged neurologically intact on hospital day 12. Discussion: VA ECMO for hemodynamic support provided the needed time for natural resolution of the cardiac toxicity while providing adequate perfusion. MARS was used in the setting of highly protein bound toxins, but drug clearance could not be demonstrated through serial levels. VA ECMO (or referral to a center with VA ECMO) should be considered with lethal loperamide-induced cardiotoxicity and perhaps other cardio-toxins.

Introduction: The intent was to evaluate time to match initial investment of a new, statewide correctional system telehealth program based upon cumulative savings by avoidance of transportation and custody-related costs., Materials and Methods: The setting was a statewide correctional system where prisoners received medical care through enhanced telemedicine technology supported by newly recruited specialty providers delivered through an open architecture system. The patients were incarcerated persons requiring nonemergent consultations in 10 specialties. A financial model was created to estimate transportation expenses, including vehicular use and custody staff, during the out of prison travel for traditional face-to-face care. Cost savings were then estimated by multiplying transportation expenses by the number of telehealth encounters (avoided cost) and summed cumulatively. Savings were mapped monthly. Private sector specialists were recruited, provided security clearance, trained in the use of the technology, and provided a secure site to provide services., Measurements and Main Results: Based on the financial model, 1.2 million dollars in savings, equaling the initial capital investment, were achieved at 32 months. The total number of patient telemedicine encounters increased from 2,365 (±98/month) to 3,748 during the first 32 months of operation (July 2013 through January 2016: ±117/month) with 89% of the established specialties performed by telemedicine technologies., Discussion: It was initially estimated to require 48 months to achieve the investment savings, but savings were achieved in 32 months, demonstrating greater adoption than expected. While finances were quantifiable, enhanced public safety by avoidance of out of prison time is unquantifiable, but judged to be significant.

Background: Ketamine may be used to manage pain and agitation that is refractory to what are usually considered traditional agents such as fentanyl, propofol, benzodiazepines, and dexmedetomidine; however, literature describing the use of ketamine continuous infusions for this purpose in critically ill trauma patients is limited., Objectives: The primary objective of this study was to determine the impact of the initiation of a ketamine continuous infusion on sedative and analgesic use in critically ill trauma patients. Secondary objectives were to identify the patient population in which ketamine was initiated, assess the proportion of time patients were at their goal level of sedation, and determine the dosing patterns of adjunctive sedative agents., Methods: This single-center retrospective chart review over a 19-month period included critically ill mechanically ventilated adult trauma patients in whom a ketamine continuous infusion was initiated for management of sedation and agitation. Patients who received ketamine for other indications or by the acute pain management service were not included in this evaluation., Results: Thirty-six patients were included in the study. Patients in whom ketamine was initiated tended to be white men with blunt trauma. Overall, the initiation of ketamine was associated with a decrease in the amount of opioids and propofol used and an increase in the amount of ziprasidone and dexmedetomidine needed to achieve the goal Richmond Agitation Sedation Score. When compared with the time period before ketamine initiation, the proportion of time that patients achieved goal sedation was not significantly different after the addition of ketamine., Conclusions: Although the use of ketamine in critically ill mechanically ventilated adult trauma patients was associated with decreased opioid use, it was also associated with increased use of dexmedetomidine and ziprasidone to achieve and maintain sedation. Further examination of clinical outcomes associated with these differences in drug use in a larger population of trauma patients is warranted before routine use of ketamine for analgesia and sedation can be recommended., (© 2017 Pharmacotherapy Publications, Inc.)

This article seeks assist physicians or administrators considering establishing a Tele-ICU. Owing to an apparent domination of the Tele-ICU field by a single vendor, some may believe that there is only one design option. In fact, there are many alternative design formats that do not require the consumer to possess high-level technical expertise. As when purchasing any major item, if the consumer can formulate basic concepts of design and research the various vendors, then the consumer can develop the Tele-ICU system best for their facility, finances, availability of staff, coverage model, and quality metric goals., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda., Data Sources: Review of the published medical literature, governmental documents, and opinions of experts from the Society of Critical Care Medicine ICU Telemedicine Committee., Data Synthesis: Formal ICU telemedicine programs now support 11% of nonfederal hospital critically ill adult patients. There is increasingly robust evidence of association with lower ICU (0.79; 95% CI, 0.65-0.96) and hospital mortality (0.83; 95% CI, 0.73-0.94) and shorter ICU (-0.62 d; 95% CI, -1.21 to -0.04 d) and hospital (-1.26 d; 95% CI, -2.49 to -0.03 d) length of stay. Physicians in training report experiences with telemedicine intensivists that are positive and increased patient safety. Early studies suggest that implementation of ICU telemedicine programs has been associated with lower numbers of malpractice claims and costs. The requirements for Medicare reimbursement and states with legislation addressing providing professional services by telemedicine are detailed., Conclusions: The inclusion of an ICU telemedicine program as a major part of their critical care delivery paradigm has been implemented for 11% of critically ill U.S. adults as a solution for the problem of access to adult critical care services. Implementation of an ICU telemedicine program is one practical way to increase access and reduce mortality as well as length of stay. ICU telemedicine research including comparative effectiveness studies is urgently needed.

Technology always changes, yet change or evolution within the tele-ICU has been slow. In developing a modern telemedicine system to manage acute illness, there are several concepts the developer/administrator should consider to include "scalability," centralized/decentralized systems, open/closed architecture, inclusivity of the medical community, mobile technology, price set, and governmental regulation. The intent of this manuscript is to apply these concepts to current tele-ICU technology, explain the concepts in some depth, and finally, to speculate as to how the future tele-ICU might look.

Objective: To describe remote presence robotic utilization and examine perceived physician impact upon care in the intensive care unit (ICU)., Study Design: Data were obtained from academic, university, community, and rural medical facilities in North America with remote presence robots used in ICUs. Objective utilization data were extracted from a continuous monitoring system. Physician data were obtained via an Internet-based survey., Results: As of 2010, 56 remote presence robots were deployed in 25 North American ICUs. Of 10,872 robot activations recorded, 10,065 were evaluated. Three distinct utilization patterns were discovered. Combining all programs revealed a pattern that closely reflects diurnal ICU activity. The physician survey revealed staff are senior (75% >40 years old, 60% with >16 years of clinical practice), trained in and dedicated to critical care. Programs are mature (70% >3 years old) and operate in a decentralized system, originating from cities with >50,000 population and provided to cities >50,000 (80%). Of the robots, 46.6% are in academic facilities. Most physicians (80%) provide on-site and remote ICU care, with 60% and 73% providing routine or scheduled rounds, respectively. All respondents (100%) believed patient care and patient/family satisfaction were improved. Sixty-six percent perceived the technology was a "blessing," while 100% intend to continue using the technology., Conclusions: Remote presence robotic technology is deployed in ICUs with various patterns of utilization that, in toto, simulate normal ICU work flow. There is a high rate of deployment in academic ICUs, suggesting the intensivists shortage also affects large facilities. Physicians using the technology are generally senior, experienced, and dedicated to critical care and highly support the technology.

Telemedicine in the intensive care unit (Tele-ICU) has grown exponentially since the first formalized program in 2000. Initially, there was limited product choice, and certain capabilities have been engineered into the process with the implication of necessity. New technology is evolving, and new vendors are entering the market place, which should yield a multitude of technologies from which to select. To date, there has been no organized lexicon designed to facilitate communication, comparison, or evaluation. This article is designed as a starting point to develop a lexicon applicable to all technologies for the Tele-ICU with the goal of facilitating clinical comparisons and administrative choices.

Disaster plans, during the actual disaster, often do not function as conceived and designed. Disaster or emergency situations may not present as anticipated in planning sessions confounding the intent of disaster planners. Systems that are created and shelved awaiting the disaster may be dysfunctional when needed due to problems such as failed batteries, forgotten training, misplaced equipment, the retraining curve, or software that has not been updated. We report here the smooth and seamless transition to disaster mode from a system in daily use and therefore operational when needed.

In critically injured patients, the incidence of acute renal failure has been reported to occur in as many as 31% of patients. The use of CRRT modalities for patients following traumatic injuries is becoming more common, albeit slowly, and this therapy may impact upon long-term recovery of renal function and mortality. Historical studies investigating the early use of intermittent dialysis reported significant improvement in survival in patients who were dialyzed earlier and more vigorously than in control subjects. Early trauma patients also showed improved survival following war injuries when dialyzed prophylactically. Although there is a growing acceptance in favor of earlier renal replacement therapy, the published consensus and the practice in many centers has been to dialyze/filter relatively ill rather than relatively healthy patients. The R Adams Cowley Shock Trauma Center (STC) in Baltimore, Maryland, USA, admits over 8,000 trauma patients each year. Within the STC, a program of continuous renal replacement therapy was established in the early 1980's. We review both historical and current literature on the use of renal replacement therapies after traumatic injury, and suggest some future areas of investigation and indications for these modalities.

Background: Whether standard nutrition support is sufficient to compensate for mineral loss during continuous renal replacement therapy (CRRT) is not known., Methods: Adult men with traumatic injuries were recruited; one-half of recruits required CRRT for acute renal failure. All urine and effluent (from CRRT) were collected for 72 hours. Urine, effluent, and dialysate were analyzed for magnesium, calcium, and zinc using atomic absorption spectrometry. Urea nitrogen in blood, urine, and effluent were determined by measuring conductivity changes after the addition of urease. Blood was analyzed for magnesium and calcium as part of routine care. Intake was calculated from orders and intake records., Results: Patients receiving CRRT (n = 6) lost 23.9+/-3.1 mmol/d (mean +/- SEM) of magnesium and 69.8+/-2.7 mmol/d of calcium compared with 10.2+/-1.2 mmol/d and 2.9+/-2.5 mmol/d, respectively, lost in patients not in acute renal failure (n = 6; p < .01). Zinc intake was significantly greater than loss in both groups (p < .03). Urea nitrogen excretion did not differ between groups. Serum magnesium was 0.75+/-0.04 mmol/L for CRRT patients, significantly lower than the 0.90+/-0.03 mmol/L for control patients (p < .01). Total blood calcium was below normal in both groups; ionized calcium was below normal in CRRT patients., Conclusions: CRRT caused significant loss of magnesium and calcium, necessitating administration of more magnesium and calcium than was provided in standard parenteral nutrition formulas. However, additional zinc was not required. CRRT removed amounts of urea nitrogen similar to amounts removed by normally functioning kidneys.

Interhospital transport of the adult mechanically ventilated patient may be necessary for those who require specialized care. An experienced medical team can safely transport even the most critically ill patients if the care is optimized before departure. Patients with severe respiratory failure may have to remain on an ICU ventilator throughout the transport period, depending on the specific transport ventilator. Near-terminal ARDS can be treated with ECLS, and these patients also may be safely transported to a regional center.

Objective: To review effects of the vehicle of lorazepam, propylene glycol, in regard to lactate, osmolarity, and renal dysfunction., Design: Case report., Setting: Intensive care unit of a Level I trauma center. Patient A 36-yr-old Hispanic man who developed severe respiratory failure and required high-dose lorazepam for sedation. The patient was ventilated with low tidal volumes in a lung-protective fashion, with resultant "permissive hypercapnia." Lactates and osmolalities rose on initiation and fell, as expected, on discontinuation of the lorazepam infusion. However, there was no renal compensation for the hypercapnia except while the patient was not receiving lorazepam., Measurements and Main Result: Serial osmolalities, lactates, serum bicarbonate, PaCO2, and pH were measured during lorazepam infusion. Rise and fall of serum lactate and osmolality closely correlated with lorazepam. Serum bicarbonate rose significantly while the patient was not receiving lorazepam in response to hypercarbia and failed to rise while the patient was receiving lorazepam., Conclusion: The vehicle of lorazepam, propylene glycol, can cause hyperlactatemia and elevated osmolar gaps. However, propylene glycol may also interfere with renal tubular function and may blunt renal compensation for respiratory acidosis.

The objective of this study was to discuss the case of a patient with severe smoke inhalation-related respiratory failure treated with extracorporeal support. The study was set in a 12-bed multi-trauma intensive care unit at a level one trauma center and hyperbaric medicine center. The patient under investigation had carbon monoxide poisoning, and developed acute respiratory distress syndrome and cardiovascular collapse following smoke inhalation. Rapid initiation of extracorporeal support, extreme inverse-ratio ventilation and intermittent prone positioning therapy were carried out. Admission and serial carboxyhemoglobin levels, blood gases, and computerized tomography of the chest were obtained. The patient developed severe hypoxia and progressed to cardiovascular collapse resistant to resuscitation and vasoactive infusions. Veno-venous extracorporeal support was initiated. Cardiovascular parameters of blood pressure, cardiac output, and oxygen delivery were maximized; oxygenation and ventilation were supported via the extracorporeal circuit. Airway pressure release ventilation and intermittent prone positioning therapy were instituted. Following 7 days of extracorporeal support, the patient was decannulated and subsequently discharged to a transitional care facility,neurologically intact. Smoke inhalation and carbon monoxide poisoning may lead to life-threatening hypoxemia associated with resultant cardiovascular instability. When oxygenation and ventilation cannot be achieved via maximal ventilatory management, extracorporeal support may prevent death if initiated rapidly.

Diffuse alveolar hemorrhage secondary to systemic lupus erythematosus (SLE) may cause life-threatening respiratory failure and may be associated with multiple organ failure. Extensive support may be necessary to sustain life while systemic therapy becomes effective. We report here a patient with profound respiratory failure secondary to SLE associated with multiorgan failure, who was supported with veno-arterial extracorporeal lung assist (ECLA), veno-venous ECLA, and multiple continuous renal replacement therapies during plasmapheresis. The full spectrum of extracorporeal life support and treatment modalities was performed seamlessly by a single service within the critical care department.

Objective: To determine whether the timing of initiation of continuous renal replacement therapy (CRRT) affects outcome in patients with post-traumatic acute renal failure (ARF)., Design: The medical records of patients treated with CRRT for post-traumatic ARF were retrospectively reviewed. Chi-square testing was used to test frequencies between groups, and Student's t -test was used to compare means., Setting: A Level I trauma center., Patients: 100 Adult trauma patients treated with CRRT for ARF from 1989 to 1997. Patients were characterized as "early" or "late" starters, based upon whether the blood urea nitrogen (BUN) was less than or greater than 60 mg/dl, prior to CRRT initiation., Results: The mean BUN of the early and late starters was 42.6 and 94.5 mg/dl, respectively (p < 0.0001). CRRT was initiated earlier in the hospital course of early starters compared to late starters (hospital day 10.5 vs 19.4, p < 0.0001). Creatinine clearance prior to CRRT did not differ statistically between the two groups. No significant difference was found between early and late starters with respect to Injury Severity Score, admission Glasgow Coma Scale, presence of shock at admission, age, gender distribution, or trauma type. Admission laboratory values including BUN, serum creatinine, lactate, and bilirubin as well as fluid and blood requirements in the first 24 h were statistically the same for the two groups, suggesting a similar risk of developing renal failure. Survival rate was significantly increased among early starters compared to late starters (39.0 vs 20. 0 %, respectively, p = 0.041)., Conclusions: This retrospective review indicates that an earlier initiation of CRRT, based on pre-CRRT BUN, may improve the rate of survival of trauma patients who develop ARF.

Group A streptococcus has emerged as a major cause of aggressive life-threatening deep-seated infections. In addition, toxic shock syndrome caused by Group A streptococcus was recognized in 1983. Group A streptococcus produces several potent exotoxins which explain the pathophysiology of these invasive infections. Other virulence factors such as M protein, which can impede phagocytosis, are associated with some Group A streptococcus. M protein and streptococcal pyrogenic exotoxins may act as super antigens. Host factors may influence the severity of infection. Blood purification techniques such as continuous renal replacement therapy and plasmapheresis can remove streptococcal exotoxins as well as inflammatory mediators. Replacement with fresh-frozen plasma corrects coagulopathy and may provide some antibody protection. Four patients with Group A streptococcus-toxic shock syndrome treated with continuous renal replacement therapy, plasmapheresis, or both showed dramatic, rapid improvement in cardiovascular dynamics and respiratory parameters. Two patients died. The mainstay of treatment for Group A streptococcus-toxic shock syndrome remains early diagnosis, aggressive surgical control of the infection, and appropriate antibiotics (i.e., penicillin and clindamycin). Flush resuscitation may rescue some patients from profound toxic shock. The mechanisms of action need to be delineated.

Extracorporeal lung assist (ECLA) allowed surgical repair of a ruptured descending thoracic aorta to be performed in a patient with profound respiratory failure. Dense acute respiratory distress syndrome (ARDS) developed during his 15-day hospitalization at a regional trauma center. After transfer to a Level I facility, an additional injury was diagnosed: traumatic rupture of the aorta, contained within a pseudoaneurysm. ECLA by the veno-venous route was required immediately preoperatively and distal aortic perfusion was performed during the aortic repair. Despite deflation of the left lung, the patient was oxygenated and ventilated adequately during surgery. Cross-clamp time was 48 minutes. The patient was weaned from ECLA by the fifth postoperative day. To our knowledge, this is the first report of concurrent veno-venous pulmonary support with distal aortic perfusion.

BACKGROUND: Various estimates of the incidence and mortality rate of the acute (adult) respiratory distress syndrome (ARDS) have been published. The studies that led to those estimates were based on relatively small patient populations and employed variable diagnostic identifiers of ARDS. The purpose of this study was to estimate the incidence of ARDS and its mortality rate from a large database to which refined diagnostic criteria were applied. We conducted a retrospective review of all hospital discharges over a 4-year period, using screening criteria designed to select patients with ARDS. Discharges from all acute care hospitals in the state of Maryland were reviewed using a computer database from the Health Services Cost Review Commission (HSCRC). Patients >/= 12 years of age were included. Screening criteria consisted of ICD-9 codes 518.5 and 518.82 cross-referenced with procedural codes for ventilatory support (96.70, 96.71 and 96.72). Data were normalized to the number of cases per 100,000 people. RESULTS: During the 4-year study period there were 2,501,147 hospitalizations. Applying the ICD-9 ARDS criteria yielded lower and upper limits of 159-205, 439-568, 531-694 and 529-720 cases of ARDS for 1992, 1993, 1994 and 1995, respectively. Normalizing for a population of 5 million yields yearly lower and upper limit rates of 3.2-4.2, 8.8-11.4, 10.6-13.8 and 10.5-14.2 cases of ARDS per 100,000 people. Mortality upper and lower limit rates based upon the same duration, admissions and population were 38-49%, 39-52%, 36-47%, and 36-49%, respectively. CONCLUSIONS: The incidence of ARDS in Maryland is in the range of 10-14 cases per 100,000 people. The ARDS mortality rate is 36% to 52%, similar to that calculated in previous studies.

The Seldinger technique is commonly used to change central venous access catheters in the Intensive Care Unit. These catheters are routinely being changed to prevent septic complications. Some of these changes are performed by an "over-wire" technique. To assess the utility of postprocedural chest X-rays on critically ill patients after an over-wire catheter change, we followed 68 patients after they had 80 catheter changes. This study assesses catheter position by use of a postprocedural X-ray. During the study, we found no misplaced catheters and minimum symptomatology in 80 patients. The trauma/critical care fellows performing the procedures rated them as easy in 97.5 percent of the changes. The conclusion of the study is that, if the catheter change is technically easy and the patient has no symptoms, a postprocedural X-ray is not necessary.

Objective: To determine glucose balance during dextrose-free continuous hemodiafiltration with or without dextrose-containing ultrafiltrate replacement fluid and full nutritional support., Design: Prospective, nonrandomized, observational study., Setting: A 24-bed multiple trauma critical care unit in a level-I trauma center., Patients: Seventeen multiple trauma patients with multiple organ dysfunction syndrome requiring hemodialysis for acute renal failure., Interventions: Continuous hemodiafiltration effluent volume and glucose concentration were measured. Study days were classified according to whether dextrose was used in the ultrafiltrate replacement therapy. Use of dextrose in replacement therapy was determined clinically. Parenteral nutrition was not altered for potential glucose absorption from continuous hemodiafiltration. Ultrafiltrate replacement consisted of 5% dextrose in saline on 21 study days (D5YES) and dextrose-free solutions on 54 study days (D5NO)., Results: The D5YES group received 316 +/- 145 g glucose/day from the ultrafiltrate replacement fluid, in addition to glucose in total parenteral nutrition (total glucose intake = 942 +/- 229 g/day in D5YES, 682 +/- 154 g/day in D5NO) (p < 0.05). Glucose loss in continuous hemodiafiltration effluent was 82 +/- 61 g/day in D5YES and 57 +/- 22 g/day in D5NO (P < 0.05), for a net glucose uptake of 8.1 +/- 2.1 mg/kg per min in D5YES and 5.4 +/- 1.5 mg/kg per min in D5NO (p < 0.05). Glucose loss was predictable when dialysate and ultrafiltrate replacement fluids were dextrose-free (R2 = 0.77), but less so when dextrose was used as ultrafiltrate replacement (R2 = 0.47)., Conclusion: Dextrose-free dialysate promotes glucose loss during continuous hemodiafiltration, but the loss is small and predictable. Use of a dextrose-containing ultrafiltrate replacement fluid results in a significant increase in glucose intake without a commensurate increase in glucose loss, and makes glucose loss in effluent less predictable.

Despite advances in respiratory and critical care medicine, the mortality from ARDS remains unchanged. Recent research suggests current ventilatory therapy may produce additional lung injury, retarding the recovery process of the lung. Alternative supportive therapies, such as ECMO and ECCO2R, ultimately may result in less ventilator induced lung injury. Due to the invasiveness of ECMO/ECCO2R, these modalities are initiated reluctantly and commonly not until patients suffer from terminal or near-terminal respiratory failure. Low flow ECCO2R may offer advantages of less invasiveness and be suitable for early institution before ARDS becomes irreversible. We describe a patient with ARDS and severe macroscopic barotrauma supported with low flow ECCO2R resulting in significant CO2 clearance, reduction of peak, mean airway pressures and minute ventilation.

Continuous arterial-venous and veno-venous hemodiafiltration are reliable methods of renal replacement therapy and are particularly suited to critically ill patients in acute renal failure. Fluid and uremic toxin removal from continuous hemodiafiltration is sufficient to allow unrestricted nutrition support. However, the hemodiafilter cannot discriminate between uremic toxins and nutrients. Therefore, the potential exists for significant nutrient loss during continuous hemodiafiltration. Amino acid loss during continuous hemodiafiltration is approximately 10-15 g/day, although in individual cases > or = 30 g/day can be lost. Neither lipids nor intact proteins are lost to any appreciable degree during continuous hemodiafiltration. Small amounts of glucose are lost if dextrose-free dialysate is used for dialysis. If dextrose-containing dialysate is used, significant amounts of glucose can be absorbed (35-45% of the infused glucose). Fluid replacement with dextrose-containing electrolyte solutions can also lead to significant infusion of glucose. Vitamin and mineral losses during continuous hemodiafiltration are not known; neither are the vitamin requirements for patients receiving continuous hemodiafiltration. Effects of continuous hemodiafiltration on vitamin and mineral loss and status remain an important research question.

Extracorporeal life support (ELS) systems may be run by certified perfusionists, specially trained nurses or respiratory therapy staff. Guidelines for the training, certification and retraining of ELS operators have been established by the Extracorporeal Life Support Organization. Recommendations include "... a well defined program for staff training, certification, and retraining". Some clinicians have suggested that ELS operators be certified and recertified in an animal laboratory. But such practice involves veterinary expenses, animal use issues and considerable clean-up and disposal. We describe an alternative method of training, using an in vitro physiologic model designed to simulate various pathophysiologic states. In addition, the in vitro physiologic model may be used to evaluate membrane lung characteristics. This model's ease of construction, maintenance and use for training compared with live animal techniques are discussed. Research capabilities may be more flexible than with the use of the live animal technique. The in vitro physiologic model can be a useful and convenient asset to an extracorporeal membrane oxygenation/extracorporeal carbon dioxide removal (ECMO/ECCO2R) program.

Objective: To compare urea nitrogen removal by continuous hemodiafiltration vs. functional native kidneys in critically ill, septic patients receiving > 2 g of amino acids/kg body weight per day., Design: Prospective, comparative, unblinded study., Setting: Trauma critical care units of a Level I adult trauma hospital., Patients: Fifteen septic patients with multiple organ failure including renal failure who were receiving continuous hemodiafiltration; 11 septic patients with multiple organ failure without renal failure (control group). Ages of patients ranged from 18 to 60 yrs., Interventions: Collection of effluent (dialysate + ultrafiltrate) from hemodiafilters. Collection of urine from control patients., Measurements: Urea nitrogen and creatinine concentrations in blood, urine, and the hemodiafiltration effluent, measured every 24 hrs for 6 days. Effluent and urine volumes were measured., Main Results: Hemodiafilters were operational for 21.8 +/- 3.0 hrs/day. Mean urea nitrogen removal in the renal failure group was 28 +/- 10 g/day. Blood urea nitrogen was stable over the 6-day study period. In control subjects, urea nitrogen removal was 27 +/- 9 g/day, which was not significantly different from the continuous hemodiafiltration group. Blood urea nitrogen concentrations in control patients increased over the 6-day study period (p < .05). Urea nitrogen removal correlated moderately well with amino acid intake in the control group (r2 = .30), but not in the continuous hemodiafiltration group (r2 = .0004). In patients receiving continuous hemodiafiltration, effluent volume was most significantly correlated with urea nitrogen removal (r2 = .69)., Conclusions: The technique of continuous hemodiafiltration can remove substantial amounts of urea nitrogen, similar to that of normal native kidneys. In addition, at amino acid intake rates of > 2 g/kg body weight/day, urea nitrogen removal during continuous hemodiafiltration remains a function of effluent volume, so there is no need to restrict amino acid intake in acute renal failure patients supported with continuous hemodiafiltration.

Amino acid loss, plasma concentration, and the relationship between amino acid intake and balance during continuous hemodiafiltration (CHD) were investigated in a prospective, nonrandomized study of trauma patients exhibiting the systemic inflammatory response with acute renal failure. Data were compared with those from a group of similar patients who had maintained renal function (control). Both groups received similar amounts of nonprotein calories (3015 +/- 753 nonprotein calories per day in the control group vs 3077 +/- 1018 nonprotein calories per day in the CHD group) and amino acids (2.24 +/- 0.36 g/kg per day in the control group vs 2.19 +/- 0.48 g/kg per day in the CHD group) via the parenteral route. Amino acid solutions were either 19% or 45% branched-chain amino acid enriched. Studies were performed every 12 hours for a maximum of 6 days. Amino acid loss was 2.5 +/- 2.3 g/12 h in the control group vs 6.6 +/- 2.4 g/12 h in the CHD group (p < .0001). Increasing the dialysate rate from 15 to 30 mL/min increased amino acid loss from 5.7 +/- 1.7 to 7.9 +/- 2.6 g/12 h (p < .0001). Amino acid loss was unrelated to amino acid intake but was directly related to plasma amino acid concentration, CHD effluent volume, and the efficiency of filtration as measured by the ratio of filtered urea nitrogen to blood urea nitrogen (R2 = .69). A linear relationship was found between amino acid intake and balance (R2 = .991). The patterns of plasma amino acid concentrations were consistent with metabolic changes wrought by a combination of sepsis and multiple organ dysfunction and type of amino acid intake but seemed unaffected by increased amino acid loss in CHD effluent. Amino acid losses were 2 to 3 times greater from CHD than from normal kidney. However, CHD amino acid losses may not be clinically significant unless amino acid intake is restricted to levels used typically in traditional hemodialysis.

Standard care for patients with renal failure while in an intensive care unit involves traditional hemodialysis or peritoneal dialysis and protein restriction. We present a case of a patient with renal failure supported with continuous arteriovenous hemofiltration with dialysis (CAVH-D) who was given full protein alimentation. Total daily urea clearance was measured from the CAVH-D output. Protein load was 196 +/- 34 g/day while receiving total parenteral nutrition and 164 +/- 30 g/day while receiving enteral alimentation. Serum blood urea nitrogen was controlled between 40 and 75 mg/dL, except during septic episodes. Nitrogen balance was estimated based upon known alimentation protein load and measurable and estimated nitrogenous losses. The patient was potentially in nitrogen equilibrium during most of the dialysis period. The cumulative nitrogen balance was positive by 5.2 g after 67 days of dialysis. Volume of alimentation was 3.49 +/- 0.7 liters/day. With CAVH-D, the renal failure patient can receive full alimentation without volume or protein load limitations. Furthermore, nitrogen balances can be estimated easily while the patient is on CAVH-D.

Objective: To document the efficacy of continuous arteriovenous hemofiltration with dialysis following renal failure, without protein restriction, and to explore the magnitude and clinical applications of total daily urea clearance., Design: A noncomparative, descriptive account of a case series. Data were collected prospectively and analyzed retrospectively., Setting: A tertiary care facility in a statewide emergency medical services system., Patients: Twenty-eight patients with renal failure were supported by continuous arteriovenous hemofiltration with dialysis in a critical care unit during a 14-month period (21 patients with multitrauma; three patients with soft tissue infections; and four patients with multisystem organ failure who had been transferred from other hospitals). Renal failure was most commonly due to multisystem organ failure or associated with adult respiratory distress syndrome., Results: Continuous arteriovenous hemofiltration with dialysis days totaled 308 (mean 10.9). All patients received full protein alimentation (mean protein load 131 g/day). The blood urea nitrogen concentration was controlled, generally to 40 to 75 mg/dL (14.3 to 26.7 mmol/L) within 3 to 5 days. Total daily urea clearance ranged from 15 to 21 g/day. Five (18%) of the 28 patients survived., Conclusion: Continuous arteriovenous hemofiltration with dialysis appears to be effective for the control of blood urea nitrogen and clearance of urea. This modality also permits full protein alimentation. Total daily urea clearance can be calculated easily and may have important clinical uses and implications.

Objective: To describe the hospital course and outcomes of trauma patients requiring ICU stays greater than 30 days and the charges they incur., Design: A retrospective case series analysis of data collected from patient charts and trauma registry., Setting: A Level I regional trauma center that is part of a statewide trauma system., Patients: Over a 3-yr period, 87 patients (3% of all trauma ICU admissions) had prolonged stays (greater than 30 days) in the ICU; they constitute the study group. Blunt trauma was responsible for 90% of injuries, and the mean Injury Severity Score was 34 +/- 16 SD., Results: Mechanical ventilation was required for 78.5% of the time spent in the ICU. The mean time spent on mechanical ventilators was 47 +/- 23 days; in the ICU, 60 +/- 27 days; and in the hospital, 72 +/- 29 days. Infectious complications occurred in 90% and organ dysfunction was seen in 76% of patients. The overall mortality rate was 17.2% (31% for patients greater than 65 yr). Patients less than 40 yr had lower mortality rates despite a significantly higher Injury Severity Score and lower Glasgow Coma Scale score compared with those greater than 65 yr. More patients greater than 65 yr were discharged to chronic care facilities than those younger (23% vs. 5%). The number of patients followed at 3 and 12 months after discharge was 74% and 54%, respectively, with only two deaths. The mean hospital and professional charges to the patients were $101,000 +/- 61,000 and $35,000 +/- 13,000, respectively., Conclusion: Length of ICU stay was most closely associated with the need for mechanical ventilation. The presence of premorbid illness, age greater than 65 yr, and organ dysfunction was associated with increased mortality. Although trauma patients requiring prolonged ICU stays utilize many resources, the ultimate outcome may be fairly good.

Renal failure is a common sequela of mass casualty, particularly when crush injury is involved. Traditional management of renal failure with hemodialysis equipment may be difficult or inaccessible due to lack of electricity and water supply or damage to existing equipment. Furthermore, a sudden new population of renal failure patients may overwhelm an existing dialysis program. The rapid mobilization of traditional hemodialysis equipment may be delayed due to limited supply, manufacturing delays, or inventory shortages. For these reasons, we propose the use of continuous arteriovenous hemofiltration with dialysis (CAVH-D) as an alternative renal support modality for the mass casualty situation.

To evaluate the effects of reorganizing physician resources in a medical intensive care unit (MICU), we studied the impact of these changes in patients with septic shock. Patients were compared during two consecutive 12-month periods: (1) an interval in which faculty without critical care medicine (CCM) training supervised the MICU (before CCM, n = 100) and (2) following staffing with physicians formally trained in CCM (after CCM, n = 112). Acute Physiology and Chronic Health Evaluation scores were utilized to compare severity of illness and were similar for each group (29 +/- 11 before CCM vs 28 +/- 10 after CCM). However, mortality was significantly lower during the post-CCM interval (74% vs 57%, respectively). There was no significant difference in the frequency of use of mechanical ventilation (83% vs 87%), although pulmonary artery catheters (48% vs 64%) and arterial catheters (24% vs 73%) were employed more frequently after CCM. The number of subspecialty consultations and MICU and hospital length of stay were similar for both intervals. We conclude that the implementation of dedicated staffing by CCM physicians in a university hospital MICU was associated with a favorable impact on patients with septic shock.