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November 8, 2013

Concise Critical Appraisal

Can You See Retinal Hemorrhages with Increased Intracranial Pressure?

Education

Webcasts to Discuss Patient Distress and Pediatric Transfusion
Discover Clinical Breakthroughs During Congress

SCCM News

Do You Know Your SCCM Engagement Score?
2014 Award for Excellence in Medication-Use Safety
Can You See Retinal Hemorrhages with Increased Intracranial Pressure?

Child abuse is a significant problem in the United States with approximately four children dying of abuse every day, most of whom are younger than 4 years. Additionally, 1300 children are presumed to die each year following abusive head trauma. Rapid identification of non-accidental head trauma helps child-protection workers and the police protect children and apprehend and prosecute abusers.

For many years, the presence of retinal hemorrhages in an infant with a neurologic injury was thought to be diagnostic for shaken baby syndrome (SBS), and frequently these hemorrhages were the only physical finding suggestive of abuse. However, the literature supporting this assumption was lacking, and many have suggested that cardiopulmonary resuscitation and increased intracranial pressure could also cause retinal hemorrhages. In 1997, Odom et al helped dispel the notion that cardiopulmonary resuscitation could cause the types of retinal bleeding seen with SBS. The recent article by Binenbaum et al, which appeared in the August issue of Pediatrics, continues this process of validation by examining the presence of retinal hemorrhages in children with non-traumatic causes of increased intracranial pressure (ICP).

In this work, the authors recruited subjects between the ages of 1 and 17 years who were undergoing lumbar punctures. Children with a history of head trauma, indwelling ventricular catheters, lumbar drains, or brain tumors were excluded. Opening pressure (OP) measurements were obtained. OP was defined as the highest pressure sustained for 10 seconds. All subjects also underwent a dilated funduscopic examination performed by a pediatric ophthalmologist no later than 96 hours after the lumbar puncture; 93% were completed within 48 hours.

Of the 100 subjects who met inclusion criteria, 32 had an OP between 20 and 28 cm H2O, and 68 had an OP >28 cm H2O. The most common diagnosis was idiopathic intracranial hypertension, but other diagnoses included infectious disease, rheumatologic or demyelinating disease, and venous thrombosis. Optic disc swelling was noted in 74 children. Sixteen subjects had splinter optic disc hemorrhages or superficial intraretinal hemorrhages, as well as moderate to severe optic disc swelling. Retinal hemorrhages were not seen in other areas (e.g., retinal periphery), not even in one case of papilledema causing severe vision loss.

The authors claim that these findings are consistent with anecdotal experiences of other pediatric ophthalmologists who routinely perform funduscopic exams on children with increased ICP. However, they also claim that the hemorrhages seen in this study are fundamentally different from the severe hemorrhagic retinopathy typically described with SBS, which are often multilayered and deeper, &#34dot-and-blot&#34 intraretinal hemorrhages. The authors also comment on the relative infrequency of disc swelling (<9% of cases) seen with head trauma compared to the study subjects.

This study&#39s strengths lie in the number of subjects enrolled and in the fact that pediatric ophthalmologists performed the funduscopic exams. The authors acknowledged the weaknesses, which are not insignificant. First, the ICPs in these subjects were presumably chronic in nature as opposed to the circumstances seen with an acute head injury. The pattern of hemorrhage seen in acute injuries is primarily preretinal and vitreous and is, again, different from the patterns seen with SBS (or Terson syndrome). Secondly, the subjects in this study were older than those seen with SBS, but, as the authors comment, because of their open sutures and fontanelles, infants are less likely to have papilledema and associated retinal hemorrhage.

Critical care physicians, child abuse specialists, and other medical professionals are often asked to testify in court about the nature of injuries, particularly in cases of non-accidental head trauma, and must be able to support their conclusions with good medical evidence. While there is not an exhaustive supply of literature supporting the notion that significant retinal hemorrhages are diagnostic of SBS, this work provides more affirming evidence.

This Concise Critical Appraisal is authored by SCCM member Daniel E. Sloniewsky, MD. Each installment highlights journal articles most relevant to the critical care practitionerDaniel Sloniewsky is an associate professor in the Department of Pediatrics at the Stony Brook Long Island Children&#39s Hospital in Stony Brook, NY, where he is board certified in pediatrics and pediatric critical care. He completed his fellowship training at Children&#39s Memorial Hospital and Northwestern University in Chicago. His major interests are in acute pediatric pulmonary disease, transfusion medicine and ethics. He is also actively involved in resident education, Pediatric Advanced Life Support and Pediatric Fundamental Critical Care Support instruction.

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Webcasts to Discuss Patient Distress and Pediatric Transfusion

The Society of Critical Care Medicine (SCCM) will offer two non-CME webcasts in the month of November. These webcasts are complimentary for all participants. If you have questions regarding these webcasts, please contact SCCM Customer Service at +1 847 827-6888.

Reducing Distress Among Critical Illness Survivors sq-Quality-Project-Dispatch v1_0
Tuesday, November 12, 2013
12:00 p.m. Central Time (view additional time zones)
Register online today.

Nearly 800,000 Americans receive mechanical ventilation for acute respiratory failure in the intensive care unit  each year. In this webcast from the Project Dispatch series, Christopher Ethan Cox, MD, MPH, and his team explore a Patient-Centered Outcomes Research Institute-funded study and explain which of two treatments is more effective in reducing psychological distress and improving quality of life.

Made possible through a grant from the Agency for Healthcare Research and Quality (AHRQ), SCCM’s Project Dispatch aims to improve the quality, effectiveness, accessibility, and cost-effectiveness of healthcare in the United States by developing and distributing resources for critical care clinicians focused on patient-centered research.

Transfusing the Critically Ill Child: It&#39s Not Like Giving Them Kool-Aid  sq-Congress
Thursday, November 14, 2013
1:00 p.m. Central Time (view additional time zones)
Register online today.

More than 22 million units of blood are transfused in the United States annually, and understanding the risk/benefit ratio is essential. In this webcast, part of an ongoing educational effort to provide the latest information on transfusion practices  to the critical care community, Philip Spinella, MD, FCCM, Howard Corwin, MD, FCCM, Joshua Salvin, MD, MPH, and Paul Checchia, MD, FCCM, will address transfusing the critically ill child. A follow-up intermediate session on the same topic will be held at the 2014 Critical Care Congress.

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Discover Clinical Breakthroughs During Congress

Learn about clinical breakthroughs and advances in patient care during the stimulating discussions of educational symposia. Each session is presented by leading experts in critical care and offers a thorough analysis of the developments and issues affecting most intensive care unit (ICU)  environments. These sessions are complimentary for all Congress registrants, and no additional registration is needed to attend.

Strategies to Optimize Physical and Psychological Functioning in the ICU Patient
(Supported by an educational grant from Hospira)
Review the impact of pain, sedation and delirium on ICU patients, discuss mobility options for ICU patients and identify strategies for successful guideline implementation.

The Continuing Adaptation of MRSA: The Impact on Critical Care
(Supported by an educational grant from Cubist Pharmaceuticals)
Explore the clinical implications of recent changes in methicillin-resistant Staphylococcus aureus (MRSA) as a pathogenic organism and the impact on patient outcomes.

Hyponatremia in the Critical Care Patient: First Do No Harm
(Supported by an educational grant from Otsuka America Pharmaceuticals, Inc.)
Identify the risks of decreased sodium levels in the neurological ICU patient, list treatment options for hyponatremia and discuss how to improve outcomes.

Targeted Therapies for Invasive Fungal Infections: Are You Missing the Mark?
(Supported by an educational grant from Astellas)
Discuss emerging data on the epidemiology of Candida, non-Candida and mucormycoses infections in the ICU and review the data on current and emerging therapies for invasive fungal infections.

These symposia will be held on Saturday, January 11, 2014, during the 43rd Critical Care Congress.  Seating is on a first-come, first-serve basis.

Register online for Congress today using your Customer ID and password, or contact SCCM Customer Service at +1 847 827-6888.

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Do You Know Your SCCM Engagement Score?

SCCMGaugeThe SCCM Engagement Index dashboard quantifies how engaged you are with SCCM. It represents your activity level with the Society, including years of continuous membership, products ordered, conferences attended and volunteer services on various committees.

The dashboard is located at mysccm.org. Log in using your username and password, and find your engagement score below your profile. The more engaged you are with your  Society, the higher your score. Start increasing your score today!

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2014 Award for Excellence in Medication-Use Safety

The American Society of Health-System Pharmacists (ASHP) Foundation is accepting applications for the 2014 Award for Excellence in Medication-Use Safety. This award, funded by the Cardinal Health Foundation, recognizes the efforts of a pharmacist-led multidisciplinary team that has implemented medication safety improvements into its hospital or health system. Five criteria will be used to evaluate all candidates for this $50,000 award, including: scope of the medication-use system initiative, pharmacist leadership, planning and implementation, measurable outcomes and impact, and innovation and generalizability.

The winner and other finalists will be recognized at an awards ceremony and during the Opening General Session of the 2014 ASHP Midyear Clinical Meeting in Anaheim, California, USA. The winning organization&#39s accomplishments will be communicated to national pharmacy trade press and consumer media, and a representative will take part in a media outreach event during the 2015 National Patient Safety Week.

For more information, please visit www.excellenceinmeduse.org.

The Society of Critical Care Medicine and its Creative Community members provide various resources aimed at addressing the latest and most pressing issues facing critical care practitioners including drug shortages. The  Drug Shortage Task Force delivers information on the safe and consistent management of shortages as well as Drug Shortage Alerts.

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