Webcast Debates Ethics of Mandatory Vaccinations

sq-CCC_206x86Vaccinations have become a routine part of elective preventative care. However, the controversy surrounding vaccines and their use is only growing. One hot topic is the ethical implications of healthcare policies that implement mandatory vaccinations for intensive care unit (ICU) personnel.

In the inaugural webcast of the Society of Critical Care Medicine's (SCCM) new series, Controversies in Critical Care, Kristen Feemster, MD, MPH, MSHP, and Douglas Naylor Jr., MD, FCCM, will debate the evidence and ethical arguments surrounding these policies. Their opinions about the potential impact of such policies on the well-being of patients and healthcare personnel will be discussed, as well as the impact on the healthcare system and society as a whole.

Learning Objectives

  • Identify those vaccinations that are currently "a mandatory treatment" for healthcare providers working in ICU environments
  • Review the current literature and evidence in support of mandatory vaccinations for healthcare providers
  • Detail the federal or local policies that establish the legal framework for instituting this practice
  • Explore the practical and ethical arguments favoring or opposing mandatory vaccinations for ICU personnel
  • Develop a plan of action for vaccination of ICU personnel using an informed opinion on the implications of mandatory vaccinations

The webcast, Ethical Debate about Mandatory Vaccinations in ICU Personnel, will take place on Friday, December 20, 2013, at 3:00 p.m. Central Time (view additional time zones).

Register online today. The registration fee for this 60-minute webcast is $30 for SCCM members and $40 for nonmembers. Participants will receive 1 hour of continuing education credit. Please contact SCCM Customer Service at +1 847 827-6888 to inquire about the $200 group rate for institutions that will host multiple participants.

The Controversies in Critical Care webcast series is a joint project between the SCCM Research Committee and the American College of Critical Care Medicine’s Ethics Committee. This series is intended to provide insight into topics in critical care medicine for which no clear consensus or unequivocal evidence guides practice decisions.

Are Age-Specific Thresholds for Cerebral Perfusion Pressure Associated with Outcomes in Pediatric Traumatic Brain Injury?

Pediatric traumatic brain injury (TBI) remains the leading cause of mortality in children younger than 19 years. Most people think that the secondary brain injury following TBI occurs in the setting of elevated intracranial pressure (ICP) and diminished cerebral perfusion pressure (CPP). These physiologic measurements are thought to affect outcomes, so current guidelines recommend treatment of both elevated ICPs and decreased CPPs, although the thresholds for CPPs have not been well established in children. Although a smaller study looked at CPP in children with TBI, this work by Allen et al is the largest study to date that attempts to determine these thresholds.

Using a prospective, observational cohort, the authors examined data from TBI-trac, an online data repository run by the Brain Trauma Foundation. This databank collects information about patients with severe TBI and uses these data to track guideline compliance at 22 different trauma centers and for research. In this report, the authors reviewed the data on patients treated between 2000 and 2008.

In all, the authors studied 2074 records and divided the patients into categories based on age: 0-5 years (55 patients), 6-11 years (65 patients), 12-17 years (197 patients), and 18 years or older (1757 patients). They subsequently defined high and low CPP thresholds for each age group to determine if these thresholds impacted short-term survival. For those in the youngest group, the authors chose 30 mm Hg for a low CPP threshold (CPP-L) and 40 mm Hg for a high threshold (CPP-H). For subjects in the group 6-11 years, the CPP-L was 35 mm Hg and the CPP-H was 50 mm Hg. For the subjects 12 years or older, the CPP-L selected was 50 mm Hg and the CPP-H was 60 mm Hg. CPP values between the high and low thresholds were labeled as CPP-B.

Read more…

Drug Safety Alert: Acetaminophen

In August, the U.S. Food and Drug Administration (FDA) notified healthcare professionals and patients that acetaminophen has been associated with a risk of rare but serious skin reactions. Acetaminophen is commonly used to treat pain and reduce fever; it is included in many prescription and over-the-counter (OTC) products. These reactions, known as Stevens-Johnson syndrome, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis, can be fatal and can occur with first-time use or at any time it is taken. This new information resulted from a review of the FDA Adverse Event Reporting System database and the medical literature to evaluate cases of serious skin reactions associated with acetaminophen. It is difficult to determine how frequently these reactions occur, due to the widespread use of the drug, differences in usage among individuals (e.g., occasional vs. long-term use), and the length of time that the drug has been on the market; however, it is likely that these events occur rarely.

Access the complete MedWatch Safety Alert, including a link to the Consumer Update and Drug Safety Communication.

PDR Drug Alerts provides immediate, electronic delivery of safety information from the U.S. Food and Drug Administration. Society of Critical Care Medicine members can sign up to receive complimentary alerts as well as updates reflecting labeling changes.

There’s Still Time to Join an SSC Local Collaborative

SSC LogoThe Surviving Sepsis Campaign (SSC) is launching a quality improvement initiative to increase early recognition and treatment of sepsis in patients on hospital medical, surgical and telemetry units. It is seeking hospitals to participate in collaboratives in San Francisco, Chicago and the East Coast (meeting in Providence, RI). Be part of the SSC collaboratives. The application deadline has been extended, and applications are now due by November 30, 2013.

The aim of this new initiative is to study, test and disseminate tools related to the early identification and treatment of sepsis on hospital floors. Participating hospitals will select one unit to enroll in this pilot project. During the course of the collaborative, hospitals that experience significant improvements may choose to implement changes in other units outside the collaborative. At the end of the collaborative, a consensus statement will be produced along with change/tool packages free to hospitals interested in improving their own care.

The SSC Collaborative initiative is made possible through a generous grant from the Gordon and Betty Moore Foundation to continue the work of the SSC in the United States. There is no fee to join the collaborative. The Foundation’s support covers the costs of the faculty, collaborative project management, database support and benchmarking, virtual meeting support, and other related expenses.

The SSC Data Collection Tool is now available. Hospitals worldwide are encouraged to download this tool to improve the care of sepsis patients. Collecting data helps improve outcomes and inform benchmarking data. Hospitals seeking to download the Data Collection Tool should seek the help of their Information Technology Department.

The SSC has recently released new resources, including:

Pediatric Acute Kidney Injury Survey

You are invited to participate in a national survey of clinical practice patterns and awareness of the incidence and outcomes in pediatric acute kidney injury (AKI). The study, being conducted by Amanda Hassinger, MD, at the Women and Children’s Hospital of Buffalo, New York, USA, seeks to elucidate the divide between AKI research and bedside practice.

The survey consists of 25 questions about acute kidney injury and should take no longer than 15 minutes to complete. Participation is voluntary, and you are free to withdraw from this study at any time.

The study has been approved by the Children and Youth Institutional Review Board of the State University of New York at Buffalo. Participation is not associated with any risk as the survey collects no identifying information on the respondent, and all responses will be recorded anonymously. While you will not experience any direct benefits from participation, your input could inform future research and practice guidelines for the detection and management of pediatric acute kidney injury.

If you have any questions regarding the survey or this research project in general, please contact Dr. Hassinger at ahassinger@upa.chob.edu. For questions concerning your rights as a research participant, please contact the Children and Youth Institutional Review Board of the State University of New York at Buffalo (+1 716 878-7141).

By completing and submitting this survey, you are indicating your consent to participate in the study.

Your participation is greatly appreciated. Please click on the link below and complete the survey no later than January 1, 2014.

Advance Registration for Congress Ends Soon

sq-CongressDecember 4 is the last day to take advantage of advance registration discounts for the Society of Critical Care Medicine’s (SCCM) 43rd Critical Care Congress, to be held in San Francisco, California, USA, January 9 to 13, 2014. Thereafter, registration will be accepted on site only.

Register online using your Customer ID and password, or call SCCM Customer Service at +1 847 827-6888. In addition, discounted hotel rates end December 12, so; make your hotel reservation through the SCCM Housing Bureau today!

This five-day event will offer opportunities to make valuable connections and draw diverse perspectives from all members of the multiprofessional critical care team. Learn about the latest developments in critical care by attending the always-popular abstract presentations and Poster Hall events offered at Congress:

Oral Presentations
Oral presentations will be scheduled, unopposed, on Friday, January 10, 2014, from 3:45 p.m. to 5:45 p.m. These presentations will highlight the top 62 abstracts submitted.

Poster Discussions and Awards Presentations
Interact and discuss original scientific research findings with abstract authors in the Poster Hall, which will be open Friday, January 10, through Sunday, January 12, 2014. Winners of SCCM’s abstract-based awards will be recognized during a ceremony on Sunday, January 12, 2014, from 1:30 p.m. to 2:00 p.m. in Room 270 at Moscone Center South.

ePosters
In addition to visiting the standard Poster Hall, attendees will have the opportunity to view all posters in an electronic format via computers, screens and other mobile views. These posters will be searchable and will may include enhanced information to provide the most recent critical care research available.

Professor Walk Rounds
Select poster presentations will be assigned by category to noted faculty and experts who will facilitate the exchange of ideas and commentary between younger scientists and established clinicians. Presentations will be scheduled during the lunch break each day, Friday, January 10, through Sunday, January 12, 2014.

For more information on Congress, visit www.sccm.org/Congress or view the advance program.

Webcast to Discuss Ethics Surrounding Mandatory Vaccinations

In recent years, vaccinations have come under strong social and political fire. One hot topic is the ethical implications of healthcare policies that implement mandatory vaccinations for intensive care unit (ICU) personnel.

In the inaugural webcast of the Society of Critical Care Medicine’s (SCCM) new Controversies in Critical Care series, Kristen Feemster, MD, MPH, MSHP, and Douglas Naylor Jr., MD, FCCM, will debate the evidence and ethical arguments in support of these policies. Their opinions about the potential impact of these policies on the well-being of patients and healthcare personnel will be discussed as well as the potential impact of such policies on the healthcare system and society as a whole.

Learning Objectives

  • Identify those vaccinations that are currently “a mandatory treatment” for healthcare providers working in ICU environments
  • List the current literature and evidence in support of mandatory vaccinations for healthcare providers
  • Detail the federal or local policies that establish the legal framework for instituting this practice
  • Explore the practical and ethical arguments favoring or opposing mandatory vaccinations for ICU personnel
  • Develop a plan of action for vaccination of ICU personnel using an informed opinion on the implications of mandatory vaccinations

The webcast, Ethical Debate about Mandatory Vaccinations in ICU Personnel, will take place on Friday, December 20, 2013, at 3:00 p.m. Central Time (view additional time zones).

Register online today. The registration fee for this 60-minute webcast is $30 for SCCM members and $40 for nonmembers. Participants will receive 1 hour of continuing education credit. Please contact SCCM Customer Service at +1 847 827-6888 to inquire about the $200 group rate for institutions that will host multiple participants.

The Controversies in Critical Care webcast series is a joint project between the SCCM Research Committee and the American College of Critical Care Medicine’s Ethics Committee. The webcast series is intended to provide insight into topics in critical care medicine for which there is no clear consensus or unequivocal evidence for guiding practice decisions.

Early Registration Deadline for MCCKAP is Approaching

Register by November 27, 2013, to take advantage of discounted rates for the Society of Critical Care Medicine’s (SCCM) 2014 Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP).

Administered online February 27 to March 7, 2014, the MCCKAP online exam assesses critical care fellowship programs nationally. The MCCKAP exam helps program directors:

  • Prepare fellows for the subspecialty board examinations in critical care
  • Identify specific areas of strength and weakness with lists of references and key terms for missed questions
  • Assess results for each individual fellow and the overall program as well as the institution’s national ranking
  • Review preliminary scores and analysis immediately upon completion of the test

Available in both adult and pediatric formats, the exam is offered exclusively online and consists of 200 multiple-choice questions pertaining to critical care knowledge and patient management. Exam content is developed by critical care professionals experienced in exam preparation and analysis.

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

Long-Term Cognitive Impairment After Critical Illness

Long-term cognitive impairment is a significant public health problem. In the October 3 issue of the New England Journal of Medicine, the BRAIN-ICU Investigators, led by Pratik Pandharipande, MD, conducted a multicenter, prospective cohort study to estimate the prevalence of long-term cognitive impairment after critical illness and to test the hypothesis that patients with a longer duration of delirium and a higher sedative and analgesic requirement have more severe cognitive impairment up to 1 year after hospital discharge.

Adults admitted to a medical or surgical ICU with respiratory failure, cardiogenic shock, or septic shock were included. While hospitalized, they were evaluated for delirium and level of consciousness daily with the use of the Confusion Assessment Method for the ICU (CAM-ICU) and the Richmond Agitation-Sedation Scale (RASS). Global cognition and executive functions were assessed three and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status and the Trail Making Test, Part B. Multiple linear regression with adjustment for multiple variables was used to examine independent risk factors for global cognition scores and secondary outcomes.

Read more…

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.

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.

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!

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.

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.

Lung Ultrasound: Better Than a Chest Radiograph?

Ultrasound use in the intensive care unit (ICU) has become increasingly prevalent, especially as more intensivists gain valuable training and experience in this cost-effective imaging modality. In this month’s issue of Intensive Care Medicine, Xirouchaki et al compared the diagnostic performance of lung ultrasound and bedside chest radiography (CXR) for the detection of four pathologic entities: consolidation, interstitial edema, pneumothorax, and pleural effusion.

Forty-two mechanically ventilated patients in a mixed medical-surgical ICU were prospectively enrolled in this blinded, non-randomized trial. Enrollment in the trial was triggered by the need for thoracic computed tomography (CT), which was used as the gold standard for all patients. All patients had a CXR, CT, and ultrasound examination. The primary author performed all ultrasound exams and was blinded to the CT findings; the exams were not reviewed by a blinded radiologist.

Ultrasound had superior sensitivity and specificity for the detection of consolidation, pleural effusion, and interstitial edema when compared to CXR. A positive likelihood ratio of 14.29 was reported for detecting consolidation with ultrasound (100% sensitivity, 78% specificity); a likelihood ratio of 13.4 was reported for diagnosing interstitial edema (94% sensitivity, 93% specificity). Alternatively, CXR had a sensitivity of only 38% for consolidation and a sensitivity of 46% for interstitial edema. Ultrasound identified six of eight pneumothoraces with a sensitivity of 75%. None of the pneumothoraces were clinically significant. The authors concluded that lung ultrasound demonstrated superior diagnostic performance compared to CXR, and may be considered as an alternative to computed tomography (CT) in some instances.

Since patient selection was based on a predefined need for a CT, the study was subject to considerable verification bias. Moreover, all exams were performed by one investigator, and none of the exams were confirmed by a blinded radiologist or second ultrasonographer. All patients were positioned laterally for the exam, and this positioning might have changed the localization for some abnormalities, and may not always be feasible or safe for many ICU patients in other settings. The case mix, plagued by the limitation of a small sample size, was heavily skewed towards trauma patients (n=11) and patients with sepsis (n=18), further limiting the generalizability across diverse ICU patient populations.

Notwithstanding the significant limitations, this work stands as yet another example of how ultrasound might be used in the ICU as a safer and cheaper alternative to other diagnostic modalities. Training, equipment acquisition and quality control remain significant concerns that must be addressed before ultrasound can be reliably used in place of an established “gold standard” such as chest CT.

Concise Critical Appraisal is a regular feature authored by SCCM member Samuel M. Galvagno Jr., DO. Each installment highlights journal articles most relevant to the critical care practitioner.

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