Therapeutic hypothermia and controlled normothermia in the intensive care unit

From Critical Care Medicine:

Abstract:

Background: Hypothermia is being used with increasing frequency to prevent or mitigate various types of neurologic injury. In addition, symptomatic fever control is becoming an increasingly accepted goal of therapy in patients with neurocritical illness. However, effectively controlling fever and inducing hypothermia poses special challenges to the intensive care unit team and others involved in the care of critically ill patients.

Objective: To discuss practical aspects and pitfalls of therapeutic temperature management in critically ill patients, and to review the currently available cooling methods.

Design: Review article.

Interventions: None.

Main Results: Cooling can be divided into three distinct phases: induction, maintenance, and rewarming. Each has its own risks and management problems. A number of cooling devices that have reached the market in recent years enable reliable maintenance and slow and controlled rewarming. In the induction phase, rapid cooling rates can be achieved by combining cold fluid infusion (1500-3000 mL 4°C saline or Ringer’s lactate) with an invasive or surface cooling device. Rapid induction decreases the risks and consequences of short-term side effects, such as shivering and metabolic disorders. Cardiovascular effects include bradycardia and a rise in blood pressure. Hypothermia’s effect on myocardial contractility is variable (depending on heart rate and filling pressure); in most patients myocardial contractility will increase, although mild diastolic dysfunction can develop in some patients. A risk of clinically significant arrhythmias occurs only if core temperature decreases below 30°C. The most important long-term side effects of hypothermia are infections (usually of the respiratory tract or wounds) and bedsores.

Conclusions: Temperature management and hypothermia induction are gaining importance in critical care medicine. Intensive care unit physicians, critical care nurses, and others (emergency physicians, neurologists, and cardiologists) should be familiar with the physiologic effects, current indications, techniques, complications and practical issues of temperature management, and induced hypothermia. In experienced hands the technique is safe and highly effective.

P4P Unproven?

From the New York Times:

…none of the studies focused on the effect of pay-for-performance on the relationship between patients and their doctors.

In other words, we are continuing to charge ahead with pay-for-performance plans without stopping to look at what we’ve already done. And what we’ve already done may or may not be as promising as we believe or would like to hope.

Wondering if I had missed something, I called Dr. Laura A. Petersen, lead author of the most recent review of studies on pay-for-performance plans and chief of the section of health services research at Baylor College of Medicine in Houston.

Dr. Petersen had had similar concerns when she began first began sifting through clinical studies for her review. “Pay-for-performance was being implemented everywhere, so I thought that there had to be a lot of evidence,” she told me. “But I was shocked. There was only this tiny group of studies. I called everyone I knew, contacted people around the country; but there just was really nothing. I found it fascinating that a widespread policy intervention like this could spread like wildfire on the basis of no evidence.”

Night Shift

From Wired:

By closely monitoring people with disrupted sleep patterns, researchers have documented the metabolic disarray produced by working at night and sleeping during the day.

As soon as their circadian rhythms became separated from a day-night cycle, test subjects’ levels of key metabolic hormones went haywire — the most compelling evidence yet that shift work isn’t just an inconvenience, but an occupational hazard.

“Normally, the body clock prepares the body for certain activities at a certain time of day,” said study co-author Frank Scheer, a Harvard Medical School neuroscientist. “But when it’s out of synchronization, it doesn’t prepare it properly.”

For years, scientists have known that people who work night shifts — about 15 million people in the United States — are unusually prone to heart disease, bone fractures, cancer, diabetes and obesity.

The patterns were initially explained as a function of poor nutrition and low exercise, but night workers don’t necessarily live less healthy lives than their day shift counterparts. Risks remained high even when lifestyle was removed from the equation.

That left hypotheses about links between biological clocks and metabolic hormone regulation. Studies on animals suggest a connection, but relatively little research has been conducted on people engaged in shift work.

Hospital survey finds nearly half operating at loss

From Modern Healthcare:

In a survey of nearly 440 hospitals, nearly half reported a net loss at the end of September, according to a Thomson Reuters report. Thirty percent reported negative operating margins during the first nine months of the year, a troubling trend in light of the economy’s rapid and deep contraction between October and December.

The median net margin dipped below 1% to 0.12% as of Sept. 30, far from the 5.04% median net margin reported in the third quarter of 2007. The median operating margin, which does not include investments, was 2.89% as of Sept. 30, just shy of the 2.95% reported for the same quarter the prior year. Hospitals’ cash cushion gradually eroded last year when measured by the number of days a hospital can run on its reserves.

Defibrillator on sale at… Costco

$100 off -$1160.

Phillips HeartStart at Cosco

Excerpt:

Please consider these things before your purchase:

  • If you have questions or concerns about your health, or an existing medical condition, please talk with your doctor. A defibrillator does not take the place of seeking medical care.
  • You cannot use the HeartStart to treat yourself.
  • Users may need to perform CPR.
  • Responding to cardiac arrest may require you to kneel.
  • Voice instructions and enclosed materials are in English.
  • HeartStart provides audible and visible indicators when maintenance is required.