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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

New guidelines with revised diagnostic criteria for allergic bronchopulmonary aspergillosis (May 2024)

Allergic bronchopulmonary aspergillosis (ABPA), a complex hypersensitivity reaction to airway colonization with Aspergillus fumigatus , can be hard to distinguish from difficult-to-treat asthma or cystic fibrosis. The International Society for Human and Animal Mycology (ISHAM) working group for ABPA recently published revised diagnostic criteria that make some key changes to improve the sensitivity and specificity of the diagnosis [ 1 ]:

● Total serum immunoglobulin (Ig) E levels of ≥500 international units/mL are sufficient for the diagnosis, rather than the previously higher threshold of 1000 international units/mL.

● Elevated Aspergillus IgG levels by enzyme immunoassay or lateral flow assay are more sensitive for detecting sensitivity to Aspergillus antigens and should be used preferentially over Aspergillus serum precipitins.

Our authors agree with the revised ISHAM diagnostic approach ( table 1 ). (See "Clinical manifestations and diagnosis of allergic bronchopulmonary aspergillosis", section on 'Diagnostic criteria' .)

Pro-inflammatory airway phenotype associated with asthma susceptibility locus 17q21 (April 2024)

Multiple genome-wide association studies have identified the 17q21 locus as strongly associated with asthma susceptibility, but the mechanism of this association has been uncertain. In recent transcriptome-wide analyses of respiratory epithelium from three separate asthma cohorts, a strong genotype-phenotype link has been identified between the expression of Gasdermin B ( GSDMB ) and a pro-inflammatory cell-lytic type 1 immune transcriptome signature [ 2,3 ]. Higher GSDMB expression was associated with enhanced airway inflammation after respiratory viral infection both in cultured epithelial cells and in mice expressing human GSDMB in their airways. Mechanistically, GSDMB was shown to bind (virally produced) double-stranded RNA and subsequently activate pro-inflammatory signaling cascades. (See "Genetics of asthma", section on 'Expression quantitative trait (eQTL) mapping' .)

Association between gut bacteriophage abundance and asthma risk (April 2024)

The abundance and diversity of gut flora and their interaction with the immune system have been associated with a predisposition to childhood asthma. A recent study examined the role of the fecal virome, predominantly comprising temperate bacteriophages, in a Danish birth cohort of 647 one-year-old children who were subsequently longitudinally assessed for asthma [ 4 ]. The relative abundance of certain viral families was associated with subsequent asthma development, and the viromes in turn were associated with early life exposures (eg, siblings and season of birth). The association between virome and asthma was not mediated by the impact on gut bacteria, suggesting independent effects on the developing immune system. (See "Risk factors for asthma", section on 'Influence of microbiome' .)

Tapering inhaled corticosteroids in asthma patients responding to biologics (December 2023)

Strategies for tapering other asthma therapies, such as inhaled corticosteroids (ICS), for patients who achieve good asthma control with biologics has not been well studied. In an open-label, randomized trial of 168 adults with a history of severe eosinophilic asthma and good control on benralizumab and high-dose ICS, 43 patients were assigned to an ongoing high-dose ICS-formoterol regimen and 125 patients were assigned to a 32-week taper protocol (medium-, low-, and as-needed dosing of ICS-formoterol) [ 5 ]. In the tapering arm, 92 percent of patients achieved lower doses of ICS, with only 9 percent experiencing exacerbations. However, significant decreases in FEV 1 and increases in fraction of exhaled nitric oxide occurred in patients using the least amount of as-needed ICS-formoterol after their taper. These data suggest that most patients well-controlled on biologics may be successfully tapered to regimens containing medium- or low-dose ICS with long-acting bronchodilators. However, the safety and efficacy of tapering to as-needed ICS-formoterol requires further study. (See "Treatment of severe asthma in adolescents and adults", section on 'Tapering therapy' .)

Palliative telehealth for patients with COPD, HF, and ILD (February 2024)

Although adults with advanced chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) have poor quality of life, data on the efficacy of palliative care measures are limited. In a trial of 306 patients who were at high risk of death due to advanced COPD, HF, or ILD, those assigned to receive six nurse phone calls for symptom management and six social worker phone calls for psychosocial care had higher quality of life (based on standardized questionnaires) at six months compared with those who received usual care [ 6 ]. Telephonic palliative care interventions may be an important tool for patients with advanced cardiopulmonary disease. (See "Palliative care for adults with nonmalignant chronic lung disease", section on 'Use and benefits of palliative care' .)

CRITICAL CARE

SCCM guidelines on the management of hyperglycemia in critically ill patients (May 2024)

The Society of Critical Care Medicine (SCCM) has issued new guidelines for the management of hyperglycemia in critically ill adults and children [ 7,8 ]. Compared with the 2012 guidelines, emphasis was placed on the use of management protocols (with decision support tools) that avoid hypoglycemia and liberalization of blood glucose targets (eg, 7.8 to 11.1 mmol/L [140 to 200 mg/dL]) with frequent monitoring (≤1 hourly). We agree with the new SCCM recommendations. While we use a lower upper limit for blood glucose (180 mg/dL [10 mmol/L]) than that recommended by the SCCM, it is unlikely to be clinically meaningful. (See "Glycemic control in critically ill adult and pediatric patients", section on 'Our approach' .)

Machine learning model for oxygenation targets in mechanically ventilated patients (May 2024)

In mechanically ventilated patients, ideal oxygenation targets are unknown and vary depending on the population being treated. One recent study examined the ability of machine learning to individualize oxygen targets based upon data from previously published trials [ 9 ]. The use of an individual peripheral oxygen saturation (SpO 2 ) target based upon that predicted by the machine learning model would have reduced the absolute overall mortality by 6.4 percent compared with the randomized SpO 2 target. While these results are encouraging, a prospective trial is needed before a model such as this can be applied in routine practice. (See "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit", section on 'Fraction of inspired oxygen' .)

Incidence of transfusion-related acute lung injury (April 2024)

Transfusion-related acute lung injury (TRALI) is a potentially fatal complication of transfusion characterized by rapid-onset noncardiogenic pulmonary edema. The incidence is challenging to determine due to differing case definitions and reliance on passive reporting (requiring the clinician to notify the transfusion medicine service). A new meta-analysis that included approximately 176 million transfused blood components provides estimates from active surveillance studies [ 10 ]. For red blood cells, TRALI occurred with 0.17 of 10,000 units; for platelets, 0.31 of 10,000 units; and for plasma, 3.19 of 10,000 units (the incidence for plasma was much lower when two outlier studies were removed). TRALI remains rare and has been significantly reduced by mitigation measures such as excluding plasma from multiparous female donors; nevertheless, these numbers suggest it is more common than estimated by passive surveillance. (See "Transfusion-related acute lung injury (TRALI)", section on 'Epidemiology' .)

Gradual or one-step weaning for ventilatory withdrawal (April 2024)

Few studies have compared the two main approaches used to withdraw ventilatory support at the end of life: gradual weaning (gradual reduction in oxygen and pressure support with intermittent medication as needed) and one-step weaning (immediate extubation with peri-extubation medication support). A recent randomized study compared one-step weaning with a nurse-led gradual weaning algorithm in 168 patients [ 11 ]. Less respiratory distress was experienced by the 48 patients in the gradual weaning group, despite receiving less opioids and benzodiazepines. This study supports our practice of gradual weaning for most patients undergoing withdrawal of life support. However, one-step weaning may be suitable for select patients (eg, severe neurological injuries and minimal ventilatory support needs). (See "Withholding and withdrawing ventilatory support in adults in the intensive care unit", section on 'Withdrawal of ventilatory support' .)

Ideal oxygen targets in COVID-19 (April 2024)

In patients with acute respiratory failure due to coronavirus-2019 (COVID-19), ideal oxygenation targets are unclear. A recent study of spontaneously breathing or mechanically ventilated hospitalized adults with acute respiratory failure due to COVID-19 reported that targeting an arterial oxygen tension (PaO 2 ) ≥60 mmHg was associated with more days alive without ventilatory support compared with a target ≥90 mmHg [ 12 ]. However, there was no overall mortality benefit. Although the study was limited by lack of blinding and early cessation for slow enrollment, it supports our recommendation of targeting a peripheral oxygen saturation between 90 and 96 percent or PaO 2 ≥60 mmHg, when feasible. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Oxygenation targets' .)

ATS definition of a "time-limited trial" for potentially inappropriate therapies (March 2024)

When responding to requests for potentially inappropriate therapies, the American Thoracic Society (ATS) has recently promoted and defined the components of a "time-limited trial." The ATS describe it as a collaborative plan among clinicians and a patient and/or their surrogates to use life-sustaining therapy for a defined duration, after which the patient’s response to therapy informs the decision to continue care directed toward recovery, transition to comfort care, or extend the trial's duration [ 13 ]. They describe 16 core elements in four phases (consider, plan, support, and reassess) to be mostly implemented by intensivists. We agree with this approach. (See "Responding to requests for potentially inappropriate or futile therapies in adult intensive care unit", section on 'Placing limits on treatment' .)

Updated guideline on postoperative delirium in adults (February 2024)

The European Society of Anaesthesiology and Intensive Care Medicine has published an updated guideline on postoperative delirium (POD) [ 14 ]. Recommendations include preoperatively screening older adults for risk factors for POD and multicomponent nonpharmacological interventions for all patients with risk factors. In addition, review of recent evidence showed that perioperative use of dexmedetomidine was associated with a lower incidence of POD, particularly when administered postoperatively in the intensive care unit. We agree with the recommendations and often use dexmedetomidine in the perioperative period to reduce the incidence of POD in high-risk patients. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with lower risk' .)

Diagnostic errors in hospitalized patients (February 2024)

Diagnostic errors are important causes of preventable morbidity and mortality in hospitalized patients. In a retrospective cohort study conducted in 29 hospitals of 2428 adults who were transferred to an intensive care unit (ICU), 23.0 percent were judged to have experienced a diagnostic error [ 15 ]. In approximately 80 percent of these patients, errors were thought to have contributed to harm or death. Diagnostic errors in hospitalized patients can have serious consequences and are targets for safety improvements. (See "Diagnostic errors", section on 'Adult medicine' .)

Guidelines on management of acute respiratory distress syndrome (February 2024)

The American Thoracic Society recently updated their guidelines on the management of patients ventilated for acute respiratory distress syndrome (ARDS) [ 16 ]. Compared with previous recommendations, emphasis was placed on the value of systemic corticosteroid administration, early use of extracorporeal membrane oxygenation, and use of neuromuscular blockade, particularly in patients with severe ARDS. Recommendations also focus on the avoidance of recruitment maneuvers, especially prolonged maneuvers. We agree with these recommendations. (See "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Introduction' .)

New proposed definition for acute respiratory distress syndrome (February 2024)

A new "global definition" of acute respiratory distress syndrome has been proposed ( table 2 ) [ 17 ]. This new definition expands upon the older Berlin definition to include ultrasound for the evaluation of pulmonary infiltrates, the additional use of peripheral oxygen saturation/fraction of inspired oxygen (SpO 2 /FiO 2 ) to assess oxygenation, and the use of separate criteria for patients on high-flow oxygen or noninvasive ventilation. Accommodations were also made for diagnostic criteria for patients in resource-limited settings. We agree with the proposed changes and their future implementation. (See "Acute respiratory distress syndrome: Clinical features, diagnosis, and complications in adults", section on 'Clinical diagnosis' .)

Routine prone positioning not beneficial in ARDS during ECMO (January 2024)

Whether prone positioning benefits patients with acute respiratory distress syndrome (ARDS) undergoing venovenous extracorporeal membrane oxygenation (V-V ECMO) is unclear. In a recent randomized trial of 170 patients with mostly COVID-related ARDS, routine prone positioning during V-V ECMO did not alter outcomes including ECMO duration, length of stay, and 90-day mortality when compared with V-V ECMO in the supine position [ 18 ]. However, a significant proportion of patients were prone before enrollment which may have impacted the results. In addition, the results are not generalizable to the non-COVID ARDS population. Until data show benefit, we do not support the routine application of prone positioning during V-V ECMO in ARDS. (See "Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)", section on 'Management of refractory hypoxemia during ECMO' .)

Emerging microbiologic colonization in mechanically ventilated patients (January 2024)

Mechanically ventilated patients act as reservoirs for hospital-acquired pathogens, including Staphylococcus , Pseudomonas, and Aspergillus species. However, a recent surveillance study of 51 acute care and long-term health care facilities reported the emergence of two additional species in mechanically ventilated patients, Acinetobacter baumannii (31 percent of patients, and one-half were carbapenem-resistant) and Candida auris (7 percent, and one-third were newly identified) [ 19 ]. Clinicians should be aware of emerging microbiologic species in their local facility so that appropriate surveillance can be conducted and antimicrobial therapy initiated, if indicated. (See "Clinical and physiologic complications of mechanical ventilation: Overview", section on 'Aspiration and ventilator-associated pneumonia and microbial colonization' .)

Extracorporeal cardiopulmonary resuscitation (December 2023)

Extracorporeal cardiopulmonary resuscitation (ECPR) is being increasingly used, but data are limited and the benefits are uncertain. In a recent meta-analysis of 11 studies (10,000 patients) who underwent CPR, compared with standard CPR, ECPR was associated with decreased in-hospital mortality and increased long-term favorable neurologic outcome and survival at one year [ 20 ]. The benefit of ECPR was confined to patients with in-hospital cardiac arrest. These data support the growing practice of ECPR in select patients likely to benefit. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Sudden cardiac arrest (extracorporeal cardiopulmonary resuscitation)' .)

Sighs during mechanical ventilation (December 2023)

A ventilatory sigh refers to the administration of a deep breath every few minutes, which in prior studies was proven to maintain lung volume and to avoid atelectasis. However, sighs subsequently fell out of favor when high lung volumes were shown to be harmful. In a recent trial of over 500 ventilated trauma patients, compared with usual care, intermittent sigh volumes delivered every six minutes (plateau pressure 35 cm H 2 0) did not increase the number of ventilator-free days or 28-day mortality [ 21 ]. There were few adverse events, but sigh-related hypotension was seen in 2 percent. While encouraging, further data are needed before sighs can be routinely applied during mechanical ventilation. (See "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit", section on 'Intermittent sigh' .)

Heart rate control in septic shock (December 2023)

Beta blockade has the potential to limit harm from the adrenergic overdrive that occurs in septic shock. However, data to support heart rate control in patients with septic shock are limited. In a recent, unblinded randomized trial of 126 patients with septic shock-related tachycardia (heart rate ≥95/min) who were receiving norepinephrine, the beta blocker landiolol did not reduce organ failure as measured by the sequential organ failure assessment score [ 22 ]. Furthermore, landiolol was associated with increased 28-day mortality compared with standard care (37 versus 25 percent). We continue to avoid the routine use of beta blockers in patients with septic shock. (See "Investigational and ineffective pharmacologic therapies for sepsis", section on 'Heart rate control' .)

Liberal transfusion strategy for acute myocardial infarction (December 2023)

Restrictive transfusion (transfusing at a lower hemoglobin, typically <7 or 8 g/dL) is appropriate for most patients based on evidence from randomized trials, but trial data for patients with acute myocardial infarction (MI) have been slower to accumulate. In the MINT trial, which randomly assigned 3504 patients with acute MI and anemia to a restrictive or liberal (transfusing for hemoglobin <10 g/dL) strategy, there was a trend toward better outcomes with the liberal strategy without an increased risk of adverse events [ 23 ]. We now suggest a liberal strategy for acute MI. A slightly lower hemoglobin may be reasonable for stable, asymptomatic patients, and patients with hemodynamic instability may require a higher hemoglobin. (See "Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Acute MI' .)

Nasal decolonization in intensive care units (November 2023)

To reduce hospital-acquired infections, many hospitals provide nasal decolonization with either mupirocin or an iodophor to all patients in intensive care units (ICUs). In a cluster-randomized trial in over 130 hospitals that used universal nasal mupirocin and daily chlorhexidine bathing for ICU patients, switching to nasal iodophor was associated with a higher rate of Staphylococcus aureus growth on clinical cultures than continuing with mupirocin [ 24 ]. There was no difference in the rate of bloodstream infection from any pathogen. For hospitals that elect to use nasal decolonization in the ICU, we suggest mupirocin rather than iodophors. This practice may be particularly beneficial in ICUs with high rates of S. aureus infections, including methicillin-resistant strains. (See "Nosocomial infections in the intensive care unit: Epidemiology and prevention", section on 'Patient bathing plus decolonization' .)

Guidelines for fever management in critically ill patients (November 2023)

Updated guidelines on the management of fever in the intensive care unit have been recently published by the Society for Critical Care Medicine and the Infectious Diseases Society of America [ 25 ]. Differences with the previous guidelines include an emphasis on the use of core methods when feasible (eg, pulmonary artery catheter, bladder, esophageal) and oral or rectal measurement when not feasible. Also promoted was the use of bedside imaging (eg, ultrasonography) in the evaluation process and biomarkers to facilitate duration of antimicrobial therapy. We agree with the recommendations, most of which were based upon weak evidence. (See "Fever in the intensive care unit", section on 'Temperature measurement' .)

Diagnostic "mini" bronchoalveolar lavage for ventilator-associated pneumonia (November 2023)

Bronchoscopic bronchoalveolar lavage (BAL) is the gold standard for the diagnosis of ventilator-associated pneumonia (VAP). Mini-BAL is less invasive than BAL and can be performed in ventilated patients by nurses and respiratory therapists with lower rates of complications. A meta-analysis of six studies in which patients underwent both mini- and bronchoscopic BAL (in succession) reported a sensitivity of mini-BAL for VAP that was 0.9 and a specificity that was 0.83 [ 26 ]. These results confirm the role of mini-BAL as a reasonable alternative to bronchoscopic BAL for the diagnosis of VAP. (See "Clinical presentation and diagnostic evaluation of ventilator-associated pneumonia", section on 'Invasive respiratory sampling' .)

Adverse effects with piperacillin-tazobactam versus cefepime (November 2023)

Observational data have raised concerns for nephrotoxicity with piperacillin-tazobactam (when given with vancomycin ) and neurotoxicity with cefepime . In an open-label trial of over 2500 patients randomly assigned to piperacillin-tazobactam versus cefepime, the incidence of major kidney events was comparable between groups (9 versus 10 percent), including among the 1900 patients who also received vancomycin [ 27 ]. Median antibiotic use was three days. Although the incidence of neurotoxicity (primarily delirium) was higher with cefepime (21 versus 17 percent), imbalances in baseline delirium rates reduce confidence in that finding. These data reduce concern for nephrotoxicity with short-term coadministration of piperacillin-tazobactam and vancomycin (eg, for initial empiric therapy). For those who warrant prolonged therapy with vancomycin plus an antipseudomonal agent, we weigh the uncertain risks of nephrotoxicity and neurotoxicity when choosing between piperacillin-tazobactam and cefepime. (See "Beta-lactam antibiotics: Mechanisms of action and resistance and adverse effects", section on 'Renal reactions' .)

INTERSTITIAL LUNG DISEASE

LUNG CANCER

Updated lung cancer screening reporting system (Lung-RADS) (January 2024)

A new version of the lung computed tomographic screening reporting and data system (Lung-RADS [LR]) has been published ( table 3 ) [ 28 ]. LR categories of 0 to 4 were retained (ie, low-risk to high-risk findings). New changes compared with the older version include the description of atypical pulmonary cysts as well as juxtapleural and airway nodules, and new surveillance options for inflammatory lesions. Clarification was also given on the definition of a growing nodule. We agree with the updated changes. (See "Lung-RADS standardized reporting for low-dose computed tomography for lung cancer screening", section on 'Lung-RADS (LR) categories: Assigning lung cancer risk' .)

LUNG TRANSPLANTATION

Tacrolimus versus cyclosporine for chronic lung transplant rejection (January 2024)

Effective strategies for the prevention of chronic lung allograft dysfunction (CLAD), a term for chronic rejection, have been limited. In a recent trial of 249 patients, individuals randomly assigned to daily tacrolimus after lung transplantation demonstrated decreased incidence of CLAD over 36 months compared with those assigned to twice daily cyclosporine (39 versus 13 percent) [ 29 ]. Patients in the tacrolimus group had fewer acute rejection episodes and a better side effect profile. Based upon these data and findings from previous trials, we recommend tacrolimus over cyclosporine as part of the initial maintenance immunosuppression regimen for lung transplant recipients. (See "Maintenance immunosuppression following lung transplantation", section on 'Tacrolimus versus cyclosporine' .)

Thyroid hormone administration in deceased organ donors (December 2023)

Thyroid hormone administration has been a longstanding component of some organ procurement protocols due to concern that acute hypothyroidism might contribute to hemodynamic instability and left ventricular dysfunction, reducing heart and other organ procurement; however, evidence for the practice has been inconsistent. In a recent trial of 838 hemodynamically unstable, brain-dead donors assigned to receive a levothyroxine infusion or saline placebo, there was little to no difference in number of hearts transplanted or 30-day cardiac graft survival [ 30 ]. Recovery of other organs was similarly unaffected. More cases of severe hypertension or tachycardia occurred in the levothyroxine group than in the saline group. Based on these data, we suggest avoiding thyroid hormone administration in deceased organ donors. (See "Management of the deceased organ donor", section on 'Thyroid hormone' .)

PLEURAL DISEASE

Machine learning to narrow pleural effusion differential (May 2024)

Determining the etiology of a pleural effusion can be challenging. Machine learning has recently been used to help clinicians narrow the differential. One study of over 2200 patients who underwent thoracentesis found good performance when a machine learning model used 18 of 49 clinical, blood, and pleural fluid parameters to identify five common types of pleural effusion (transudative, malignant, parapneumonic, tuberculous, and other; area under the receiver operating characteristic curve 0.930 [validation set] and 0.916 [extra-validation set]) [ 31 ]. Further study in different populations and refinement are needed before a model such as this can be clinically useful. (See "Diagnostic evaluation of the hemodynamically stable adult with a pleural effusion", section on 'Making a preliminary diagnosis' .)

PULMONARY VASCULAR DISEASE

Unchanged emergency department discharge rates for pulmonary embolism (April 2024)

Outpatient anticoagulation to avoid hospitalization is safe for a select group of patients with acute pulmonary embolism (PE). However, a recent study of over 1.6 million emergency department (ED) visits for PE in the United States reported that ED discharge rates for PE were unchanged between 2012 and 2020 (38 versus 33 percent) [ 32 ]. Among low-risk patients, only one third were discharged from the ED. However, this study was unable to determine whether other factors may have prevented discharge such as drug accessibility, concurrent deep vein thrombosis, and right ventricular burden. Although not conclusive, this study suggests that increased physician awareness is needed to encourage safe ED discharge of low-risk patients with PE. (See "Treatment, prognosis, and follow-up of acute pulmonary embolism in adults" .)

Predicting venous thromboembolism risk in non-major orthopedic surgery (April 2024)

For patients with non-major extremity orthopedic injury or surgery, deciding who should undergo venous thromboembolism (VTE) prophylaxis is challenging due to the wide range of risk. The Thrombosis Risk Prediction for Patients with cast immobilization or TRiP(cast) score, which predicts VTE risk, was recently derived and validated in nearly 5000 patients with prolonged lower limb casting, mostly for ankle sprain [ 33 ]. Among those assessed as low VTE risk (score <7) and in whom anticoagulation was withheld, the rate of symptomatic VTE was 0.7 percent compared with 2.7 percent among those with a score ≥7 despite anticoagulation. The negative predictive value for this threshold was 99 percent. Use of the score reduced the prescription of anticoagulants by 26 percent compared with baseline prescription levels. While promising, further validation is needed. (See "Prevention of venous thromboembolism (VTE) in adults with non-major extremity orthopedic injury with or without surgical repair", section on 'Venous thromboembolism risk' .)

SLEEP MEDICINE

Uncertain role of adaptive servo-ventilation in patients with heart failure with reduced ejection fraction (February 2024)

In a prior trial (SERVE-HF), positive airway pressure therapy with adaptive servo-ventilation (ASV) increased mortality in patients with central sleep apnea (CSA) due to heart failure with reduced ejection fraction (HFrEF). In the subsequent ADVENT-HF trial, among 731 patients with sleep-disordered breathing (obstructive- or central-predominant) and HFrEF, ASV resulted in similar all-cause mortality relative to standard care for both the overall study population and the subgroup with CSA [ 34 ]. However, the number of patients with CSA was small and confidence intervals were wide for all outcomes. Thus, we continue to avoid use of ASV in patients with CSA due to HFrEF. (See "Central sleep apnea: Treatment", section on 'Patients with ejection fraction ≤40 percent' .)

Management of post-adenotonsillectomy obstructive sleep apnea in children (February 2024)

A new clinical practice guideline on management of persistent obstructive sleep apnea after adenotonsillectomy in children is available from the American Thoracic Society [ 35 ]. The guideline endorses a multidisciplinary evaluation, which may include drug-induced sleep endoscopy and cine magnetic resonance imaging to identify sites of obstruction and guide further interventions. It also provides conditional recommendations based on low certainty of evidence for interventions ranging from weight loss and continuous positive airway pressure to orthodontic treatments and adjuvant surgical procedures. (See "Adenotonsillectomy for obstructive sleep apnea in children", section on 'Positive airway pressure' .)

OTHER PULMONARY MEDICINE

Risk of autoimmune inflammatory rheumatic disease following COVID-19 (May 2024)

The risk of developing autoimmune inflammatory rheumatic diseases (AIRDs) following COVID-19 has recently been studied (eg, rheumatoid, psoriatic, and spondyloarthritides and connective tissue disorders) [ 36 ]. A Korean and Japanese cohort analysis of 22 million patients reported an increased risk of AIRDs in patients who had COVID-19 compared with uninfected patients (hazard ratio [HR], 1.25 [Korea], 1.79 [Japan]) and with patients who had influenza (HR, 1.30 [Korea], 1.14 [Japan]). The risk appeared to diminish over time and was likely reduced by vaccination. Clinicians should be aware of the risk of AIRD following COVID-19 and investigate appropriately when suspected. (See "COVID-19: Clinical presentation and diagnosis of adults with persistent symptoms following acute illness ("long COVID")", section on 'Physical symptoms' .)

Benralizumab in the treatment of eosinophilic granulomatosis with polyangiits (March 2024)

Eosinophilic granulomatosis with polyangiitis (EGPA) is a chronic inflammatory disorder associated with asthma, chronic rhinosinusitis with or without polyposis, and peripheral blood eosinophilia that may be amenable to treatment with biologic agents targeting eosinophilic inflammation via the interleukin-5 (IL-5) pathway. In a randomized trial of 140 patients with relapsing or refractory EGPA, 59 percent of patients receiving benralizumab , an antibody targeting the IL-5 receptors, and 56 percent of patients receiving mepolizumab , an antibody targeting IL-5, achieved remission of disease [ 37 ]. Serious adverse events were uncommon and similar in each group. Based upon these findings, we suggest benralizumab or mepolizumab as glucocorticoid-sparing therapeutic options for individuals with non-severe relapsing or refractory EGPA. (See "Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): Treatment and prognosis", section on 'Anti-IL-5 or anti-IL-5R agents' .)

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• Carson JL, Brooks MM, Hébert PC, et al. Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia. N Engl J Med 2023; 389:2446.
• Huang SS, Septimus EJ, Kleinman K, et al. Nasal Iodophor Antiseptic vs Nasal Mupirocin Antibiotic in the Setting of Chlorhexidine Bathing to Prevent Infections in Adult ICUs: A Randomized Clinical Trial. JAMA 2023; 330:1337.
• O'Grady NP, Alexander E, Alhazzani W, et al. Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU. Crit Care Med 2023; 51:1570.
• Tepper J, Johnson S, Parker C, et al. Comparing the Accuracy of Mini-BAL to Bronchoscopic BAL in the Diagnosis of Pneumonia Among Ventilated Patients: A Systematic Literature Review. J Intensive Care Med 2023; 38:1099.
• Qian ET, Casey JD, Wright A, et al. Cefepime vs Piperacillin-Tazobactam in Adults Hospitalized With Acute Infection: The ACORN Randomized Clinical Trial. JAMA 2023; 330:1557.
• https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/Lung-Rads (Accessed on January 05, 2024).
• Dellgren G, Lund TK, Raivio P, et al. Effect of once-per-day tacrolimus versus twice-per-day ciclosporin on 3-year incidence of chronic lung allograft dysfunction after lung transplantation in Scandinavia (ScanCLAD): a multicentre randomised controlled trial. Lancet Respir Med 2024; 12:34.
• Dhar R, Marklin GF, Klinkenberg WD, et al. Intravenous Levothyroxine for Unstable Brain-Dead Heart Donors. N Engl J Med 2023; 389:2029.
• Kim NY, Jang B, Gu KM, et al. Differential Diagnosis of Pleural Effusion Using Machine Learning. Ann Am Thorac Soc 2024; 21:211.
• Watson NW, Carroll BJ, Krawisz A, et al. Trends in Discharge Rates for Acute Pulmonary Embolism in U.S. Emergency Departments. Ann Intern Med 2024; 177:134.
• Nemeth B, Douillet D, le Cessie S, et al. Clinical risk assessment model to predict venous thromboembolism risk after immobilization for lower-limb trauma. EClinicalMedicine 2020; 20:100270.
• Bradley TD, Logan AG, Lorenzi Filho G, et al. Adaptive servo-ventilation for sleep-disordered breathing in patients with heart failure with reduced ejection fraction (ADVENT-HF): a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial. Lancet Respir Med 2024; 12:153.
• Ehsan Z, Ishman SL, Soghier I, et al. Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2024; 209:248.
• Kim MS, Lee H, Lee SW, et al. Long-Term Autoimmune Inflammatory Rheumatic Outcomes of COVID-19 : A Binational Cohort Study. Ann Intern Med 2024; 177:291.
• Wechsler ME, Nair P, Terrier B, et al. Benralizumab versus Mepolizumab for Eosinophilic Granulomatosis with Polyangiitis. N Engl J Med 2024; 390:911.

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Welcome to the ATS Critical Care website. We hope that this site will be a resource for clinical tools and educational material that enhance your work at the bedside, on rounds, and in the laboratory.

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Web Director: Sarina Sahetya, MD, MHS

The American Thoracic Society improves global health by advancing research, patient care, and public health in pulmonary disease, critical illness, and sleep disorders. Founded in 1905 to combat TB, the ATS has grown to tackle asthma, COPD, lung cancer, sepsis, acute respiratory distress, and sleep apnea, among other diseases.

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Page 1 of 374

Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations

The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and r...

• View Full Text

Acute kidney injury after out-of-hospital cardiac arrest

Acute kidney injury (AKI) is a significant risk factor associated with reduced survival following out-of-hospital cardiac arrest (OHCA). Whether the severity of AKI simply serves as a surrogate measure of wors...

Development and validation of the tic score for early detection of traumatic coagulopathy upon hospital admission: a cohort study

Critically injured patients need rapid and appropriate hemostatic treatment, which requires prompt identification of trauma-induced coagulopathy (TIC) upon hospital admission. We developed and validated the pe...

Challenging ICU dogmas: a new perspective on venous congestion and preload dependency

The original article was published in Critical Care 2024 28 :52

Protocolized reduction of non-resuscitation fluids versus usual care in septic shock patients (REDUSE): a randomized multicentre feasibility trial

Non-resuscitation fluids constitute the majority of fluid administered for septic shock patients in the intensive care unit (ICU). This multicentre, randomized, feasibility trial was conducted to test the hypo...

Effects of mechanical ventilation on the interstitial extracellular matrix in healthy lungs and lungs affected by acute respiratory distress syndrome: a narrative review

Mechanical ventilation, a lifesaving intervention in critical care, can lead to damage in the extracellular matrix (ECM), triggering inflammation and ventilator-induced lung injury (VILI), particularly in cond...

Causes and attributable fraction of death from ARDS in inflammatory phenotypes of sepsis

Hypoinflammatory and hyperinflammatory phenotypes have been identified in both Acute Respiratory Distress Syndrome (ARDS) and sepsis. Attributable mortality of ARDS in each phenotype of sepsis is yet to be det...

Predicting outcome after aneurysmal subarachnoid hemorrhage by exploitation of signal complexity: a prospective two-center cohort study

Signal complexity (i.e. entropy) describes the level of order within a system. Low physiological signal complexity predicts unfavorable outcome in a variety of diseases and is assumed to reflect increased rigi...

Efficacy of expanded periurethral cleansing in reducing catheter-associated urinary tract infection in comatose patients: a randomized controlled clinical trial

The effect of the periurethral cleansing range on catheter-associated urinary tract infection (CAUTI) occurrence remains unknown. The purpose of this study was to evaluate the efficacy of expanded periurethral...

qSOFA combined with suPAR for early risk detection and guidance of antibiotic treatment in emergency department: a bit sweet and a bit sour randomized controlled trial

The original article was published in Critical Care 2024 28 :42

Organ donation after extracorporeal cardiopulmonary resuscitation: a nationwide retrospective cohort study

Limited data are available on organ donation practices and recipient outcomes, particularly when comparing donors who experienced cardiac arrest and received extracorporeal cardiopulmonary resuscitation (ECPR)...

Potential implications of long-acting GLP-1 receptor agonists for critically ill

Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis.

An increasing number of patients requires extracorporeal membrane oxygenation (ECMO) for life support. This supportive modality is associated with nosocomial infections (NIs). This systematic review and meta-a...

Effect of immediate initiation of invasive ventilation on mortality in acute hypoxemic respiratory failure: a target trial emulation

Invasive ventilation is a fundamental treatment in intensive care but its precise timing is difficult to determine. This study aims at assessing the effect of initiating invasive ventilation versus waiting, in...

Machine learning derived serum creatinine trajectories in acute kidney injury in critically ill patients with sepsis

Current classification for acute kidney injury (AKI) in critically ill patients with sepsis relies only on its severity-measured by maximum creatinine which overlooks inherent complexities and longitudinal eva...

Extent of microbial over-identification of endotracheal aspirate versus bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia

Past, present, and future of sustainable intensive care: narrative review and a large hospital system experience.

Healthcare systems are large contributors to global emissions, and intensive care units (ICUs) are a complex and resource-intensive component of these systems. Recent global movements in sustainability initiat...

The neurovanguard concept and real-world embracement

The original article was published in Critical Care 2024 28 :104

The original article was published in Critical Care 2024 28 :137

Effects of non-invasive respiratory support in post-operative patients: a systematic review and network meta-analysis

Re-intubation secondary to post-extubation respiratory failure in post-operative patients is associated with increased patient morbidity and mortality. Non-invasive respiratory support (NRS) alternative to con...

Inflammatory subphenotypes previously identified in ARDS are associated with mortality at intensive care unit discharge: a secondary analysis of a prospective observational study

Intensive care unit (ICU)-survivors have an increased risk of mortality after discharge compared to the general population. On ICU admission subphenotypes based on the plasma biomarker levels of interleukin-8,...

Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study

Prior assessments of critical care outcomes in patients with cirrhosis have shown conflicting results. We aimed to provide nationwide generalizable results of critical care outcomes in patients with decompensa...

Generative artificial intelligence is infiltrating peer review process

Sepsis mortality among patients with haematological malignancy admitted to intensive care 2000–2022: a binational cohort study.

Sepsis occurs in 12–27% of patients with haematological malignancy within a year of diagnosis. Sepsis mortality has improved in non-cancer patients in the last two decades, but longitudinal trends in patients ...

Bias caused by sample selection for lower respiratory tract microbiome research

The original article was published in Critical Care 2024 28 :133

Effects of extracorporeal CO 2 removal on gas exchange and ventilator settings: a systematic review and meta-analysis

A systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO 2 R) on gas exchange and respiratory settings in critically ill adults with respiratory failure.

The effectiveness of a brief intervention for intensive care unit patients with hazardous alcohol use: a randomized controlled trial

Screening for hazardous alcohol use and performing brief interventions (BIs) are recommended to reduce alcohol-related negative health consequences. We aimed to compare the effectiveness (defined as an at leas...

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study

Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based ...

Intermittent intravenous paracetamol versus continuous morphine in infants undergoing cardiothoracic surgery: a multi-center randomized controlled trial

To determine whether intermittent intravenous (IV) paracetamol as primary analgesic would significantly reduce morphine consumption in children aged 0–3 years after cardiac surgery with cardiopulmonary bypass.

Clinical validation of a capnodynamic method for measuring end-expiratory lung volume in critically ill patients

End-expiratory lung volume (EELV) is reduced in mechanically ventilated patients, especially in pathologic conditions. The resulting heterogeneous distribution of ventilation increases the risk for ventilation...

Stress & strain in mechanically nonuniform alveoli using clinical input variables: a simple conceptual model

Clinicians currently monitor pressure and volume at the airway opening, assuming that these observations relate closely to stresses and strains at the micro level. Indeed, this assumption forms the basis of cu...

Fluid responsiveness and venous congestion: unraveling the nuances of fluid status

Beta-blockade in v-v ecmo.

The original article was published in Critical Care 2023 27 :360

Quantitative analysis of apparent diffusion coefficients to predict neurological prognosis in cardiac arrest survivors: an observational derivation and internal–external validation study

This study aimed to validate apparent diffusion coefficient (ADC) values and thresholds to predict poor neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors by quantitatively analysing the ...

Adapting NeuroVanguard to real-world challenges

The Matters Arising to this article has been published in Critical Care 2024 28 :153

Respiratory drive heterogeneity associated with systemic inflammation and vascular permeability in acute respiratory distress syndrome

In acute respiratory distress syndrome (ARDS), respiratory drive often differs among patients with similar clinical characteristics. Readily observable factors like acid–base state, oxygenation, mechanics, and...

Transforming research to improve therapies for trauma in the twenty-first century: an alternative perspective

The original article was published in Critical Care 2024 28 :45

Case study observational research: inflammatory cytokines in the bronchial epithelial lining fluid of COVID-19 patients with acute hypoxemic respiratory failure

In this study, the concentrations of inflammatory cytokines were measured in the bronchial epithelial lining fluid (ELF) and plasma in patients with acute hypoxemic respiratory failure (AHRF) secondary to seve...

Lower airway microbiota compositions differ between influenza, COVID-19 and bacteria-related acute respiratory distress syndromes

Acute respiratory distress syndrome (ARDS) is responsible for 400,000 deaths annually worldwide. Few improvements have been made despite five decades of research, partially because ARDS is a highly heterogeneo...

The Matters Arising to this article has been published in Critical Care 2024 28 :147

Rapidly improving ARDS differs clinically and biologically from persistent ARDS

Rapidly improving acute respiratory distress syndrome (RIARDS) is an increasingly appreciated subgroup of ARDS in which hypoxemia improves within 24 h after initiation of mechanical ventilation. Detailed clini...

Ventilator-associated pneumonia related to extended-spectrum beta-lactamase producing Enterobacterales during severe acute respiratory syndrome coronavirus 2 infection: risk factors and prognosis

Patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) and requiring mechanical ventilation suffer from a high incidence of ventilator associated pneumonia (VAP), mainly relate...

ACE inhibitors and angiotensin receptor blockers differentially alter the response to angiotensin II treatment in vasodilatory shock

Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blockers (ARB) medications are widely prescribed. We sought to assess how pre-admission use of these medications might impact the respons...

Time-dependent effect of prone position in ARDS: considerations for future research

The original article was published in Critical Care 2023 27 :462

Policy framework for the utilization of generative AI

Significance of critical closing pressures (starling resistors) in arterial circulation, extracorporeal cardiopulmonary resuscitation versus conventional cpr in cardiac arrest: be aware of the temporal selection bias.

The original article was published in Critical Care 2024 28 :57

Effect of intra-arrest transport, extracorporeal cardiopulmonary resuscitation and immediate invasive assessment in refractory out-of-hospital cardiac arrest: a long-term follow-up of the Prague OHCA trial

Randomized data evaluating the impact of the extracorporeal cardiopulmonary resuscitation (ECPR) approach on long-term clinical outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) are la...

Contribution of electrical impedance tomography to personalize positive end-expiratory pressure under ECCO 2 R

Extracorporeal Carbon Dioxide Removal (ECCO 2 R) is used in acute respiratory distress syndrome (ARDS) patients to facilitate lung-protective ventilatory strategies. Electrical Impedance Tomography (EIT) allows ind...

Impact of attaining aggressive vs. conservative PK/PD target on the clinical efficacy of beta-lactams for the treatment of Gram-negative infections in the critically ill patients: a systematic review and meta-analysis

To perform a systematic review with meta-analysis with the dual intent of assessing the impact of attaining aggressive vs. conservative beta-lactams PK/PD target on the clinical efficacy for treating Gram-nega...

Smoking on the risk of acute respiratory distress syndrome: a systematic review and meta-analysis

The relationship between smoking and the risk of acute respiratory distress syndrome (ARDS) has been recognized, but the conclusions have been inconsistent. This systematic review and meta-analysis investigate...

Correction to: Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

The original article was published in Critical Care 2023 27 :487

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Medical students and other students in training have a unique opportunity to volunteer during the 2024 Critical Care Congress. In return, students receive complimentary registration.

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Dates for the Critical Care Congress will be changing from January or February to March or April starting in 2026. The change in dates will allow the Society to consider additional Congress locations. Congress has been held in January or February for many years, but it was initially held in May.   This change is being made for three primary reasons:

• Congress participation has increased, and only a limited number of cities are suitable for a conference the size of Congress in January or February. Moving to March or April increases the pool of cities that can accommodate a conference the size of Congress.
• Rotating through a greater number of cities will provide increased access and more selection for SCCM members and clinicians. Because most SCCM members are in high-population centers clustered around the U.S. Great Lakes and the U.S. East Coast, Congress will be held in those areas some years, which was not possible without a change in dates to March or April.
• The new dates move Congress away from winter months, when ICUs typically see surges of influenza, COVID-19, and other infectious diseases. These surges further stress workforce issues that restrict clinicians’ ability to attend Congress.

  A list of confirmed Congress dates and location is available at sccm.org/futurecongress .

SCCM’s priority is making Congress as accessible as possible to as many participants as possible. Congress has many complex needs, and SCCM is dedicated to evaluating all suitable opportunities throughout the United States while working to contract Congress locations five to eight years in advance.

• Working with destination management organizations, hotel representatives, and local chambers of commerce to identify minority businesses that SCCM can collaborate with and support during Congress
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Atrial Fibrillation

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EKG at a glance

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Management of COPD

Invasive Fungal infections in ICU

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Perioperative Anticoagulation

Human Granulocytic Anaplasmosis

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• Medical Student's Guide to the ICU - from the Society of Critical Care Medicine
• Critical Care Medicine Tutorials - A collection of tutorials from the Gasworks Group

Core topics

• Airway objectives P Melanson, MD
• Acute respiratory failure P Melanson, MD
• Introduction to Mechanical Ventilation Erin Monaghan, RRT
• Management of Post-op Cardiac Surgery Patients
• Continuous Renal Replacement Therapy (CVVH, CVVHD) D Payen, MD
• Invasive Procedures On-line Training Modules from EMEDU.org
• Pulmonary Artery Catheter Education Project - hemodynamic monitoring/Swan-Ganz

Airway series - Pat Melanson, MD

• Airway teaching objectives
• Basic emergency airway management slides
• Bag-mask-ventilation slides
• Emergency airway management
• Rapid sequence intubation slides
• Difficult airway management slides
• The Difficult Airway Kit - Devices and techniques
• Advanced airway management
• Acute Respiratory Failure Pat Melanson, MD
• CPAP BiPAP Pat Melanson, MD
• Preventing intubation in acute respiratory failure Pat Melanson, MD
• Massive Hemoptysis D Laporta, MD
• Pericardial tamponade Pat Melanson, MD
• Hypertensive Emergencies Pat Melanson, MD
• Hemodynamic Monitoring N Christou, MD
• Shock D Laporta
• GI Bleed N Christou, MD
• Acute Pancreatitis A M. Albert, MD
• Acute Pancreatitis B M. Albert, MD
• Fulminate hepatic failure Pat Melanson, MD
• Renal Replacement Therapy in the ICU - A link to Medical Education Rounds, St Paul's Hospital, Vancouver, BC
• Acute Renal Failure Pat Melanson, MD

No information available at this time.

• Soft Tissue Infections N Christou, MD
• Antibiotic Therapy for Intra-Abdominal Infections N Christou, MD
• SIRS - Diffuse severe peritonitis study, phase 1 N Christou, MD
• Blood component therapy Pat Melanson, MD
• Stroke Therapy in the Age of Thrombolysis Mark Angle, MD
• Guidelines for the ED Management of Acute CVA Pat Melanson, MD
• Blood Pressure Management in Acute CVA Pat Melanson, MD
• Cerebral vasospasm in SAH Mark Angle MD
• Obstetrics in Critical Care D Laporta, MD
• Heat Illness Pat Melanson, MD
• Burns N Christou, MD

Toxicology series - Pat Melanson, MDe

• Toxicology: General management principles
• Toxicology references
• Tricyclic antidepressants
• Acetaminophen
• Beta-blockers
• Calcium channel blockers
• Theophylline
• Drug-induced hyperthermia
• Toxicology: General measures
• Bioethics for clinicians (Canadian Medical Association)
• Ethics Curriculum - Royal College of Physicians and Surgeons of Canada
• Guidelines for Transfer of the Critically Ill - SCCM

ICU Administration

• ICU Triage and Admission Criteria
• ICU Scoring Systems N Christou, MD
• Use of Corticosteroids in the ICU D Laporta, MD

Department and University Information

Department of critical care.

Critical Care Northampton

Reviewing Critical Care, Journals and FOAMed

General ICU Topics

ABG Analysis

Continuous Veno Venous Haemofiltration

IV Fluid Therapy

Basic Maintenance

O2 Delivery

Shock – A General Definition

Shock – A Guide on How to Distinguish Types

Shock – Anaphylactic

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Shock – Compensatory Mechanisms

Shock – Diagnosis

Shock – Diagnosis & Treatment

Shock – Dissociative

Shock – Haemodynamics

Shock – Hypovolaemic

Shock – Neurogenic

Shock – O2 Delivery

Shock – Septic

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Sepsis in 5 minutes!

Sepsis – Consensus definitions

Sepsis – Endothelial Barrier Dysfunction 3D

Sepsis – IV Fluid Resuscitation

Lactate – How sick is your patient?!

Pulmonary Artery Catheter Traces

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Key concepts, preclass activity, introduction, importance of pharmacist care for critically ill patients, patient care in the intensive care unit, specific considerations for critically ill patients, safe use of medications, pharmacoeconomics, postclass activity, abbreviations, learning objectives.

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Watch the video “ICU episode 1, season 1” at https://youtu.be/bSJnu5Btdmg . This short video provides insight into the complexity of care provided in a contemporary intensive care setting, as well as the differences in the care required of critically ill patients compared to patients in general care units. The video is useful to enhance student understanding regarding the COLLECT and ASSESS steps in the patient care process.

History of Critical Care Pharmacy

Creation of the Clinical Pharmacy and Pharmacology section within the Society of Critical Care Medicine (SCCM; 1989)

Creation of the Critical Care Practice and Research Network within the American College of Clinical Pharmacy (1992)

Critical care pharmacists recognized as integral member of the interdisciplinary team (2001)

Appointment of the first pharmacist to serve as the president of SCCM (2010)

Appointment of the first pharmacist to serve as the president of the Neurocritical Care Society (2017)

Numerous pharmacists being awarded the designation of the Fellow or Master of the American College of Critical Care Medicine

Pharmacist serving on critical care medicine guideline committees, including as first and senior authors

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The interdisciplinary patient care team, general care, post-intensive care syndrome, cardiovascular, respiratory.

ARDS = acute respiratory distress syndrome

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End-of-life care.

Formulate a plan for the aspects of care that should be applied in every critically ill patient (FAST HUGS BID) including the selection of drugs, dosing, and monitoring assuming normal renal and liver function.

Read the executive summary of the safe medication use guidelines and describe the role of the clinician in ensuring the prevention of medication errors and adverse drug events in the ICU.

Kane-Gill SL, Dasta JF, Buckley MS, et al. Executive summary: Clinical Practice Guideline: Safe Medication Use in the ICU. Crit Care Med 2017;45:1546-51.

Upon completion of the chapter, the reader will be able to:

Propose pharmacotherapy considerations specific to critically ill patients.

Compare and contrast the unique attributes of patient care required for different types of ICUs.

Recommend the aspects of patient care that should be applied in every critically ill patient.

Describe the relevance of pharmacoeconomic considerations in the ICU environment.

Explain safe medication use concerns specific to the critically ill patient.

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Integrated Critical Care Curriculum for the Third-Year Internal Medicine Clerkship

Daniel gergen.

1 Resident, Internal Medicine Residency Training Program, University of Colorado School of Medicine

Joshua Raines

Bryan lublin.

2 Assistant Professor, Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine

Anna Neumeier

3 Assistant Professor, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine

Christopher King

4 Assistant Professor, Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine

Associated Data

• Facilitator Guide.docx
• Student Welcome Email.docx
• ICU Curriculum Syllabus.docx
• ICU Presentation Template.pdf
• ICU Student Handout.pdf
• End-of-Curriculum Survey.docx

All appendices are peer reviewed as integral parts of the Original Publication.

Introduction

A majority of residents provide care for critically ill patients, yet only a minority of medical schools require ICU rotations. Therefore, many medical students enter residency without prior ICU experience. The third-year internal medicine (IM) clerkship at our institution's Veterans Affairs Medical Center (VAMC) provided an opportunity for medical students to rotate through an open ICU as part of their inpatient ward rotation. Prior to March 2019, no structured critical care curriculum existed within the IM clerkship to prepare students for this experience.

We created a seven-session ICU curriculum integrated within the VAMC IM clerkship addressing core critical care topics and skills including bedside presentations, shock, and respiratory failure. IM residents facilitated the curriculum's case-based, small-group discussions. We assessed curricular efficacy and impact with a pre- and posttest and end-of-curriculum survey.

Forty-one students participated in the curriculum from March to November 2019. As a result, students agreed that their overall clerkship experience improved (73% strongly agree , 24% agree ). Students also reported increased comfort in their ability to participate in the management of critically ill patients (44% strongly agree , 51% agree ). Objectively, student performance on a 15-question pre- and posttest improved from a precurricular average of 7.5 (50%) questions correct to a postcurricular average of 10.7 (71%) questions correct ( p <.0001; CI 2.2–4.4).

Following implementation of our ICU curriculum, medical student attitudes regarding overall IM clerkship experience, self-perceived confidence in critically ill patient management, and medical knowledge all improved.

Educational Objectives

By the end of this activity, learners will be able to:

• 1. Apply a standardized approach to rounding presentations in the medical ICU.
• 2. Describe a physical exam-based approach for working through the differential diagnosis in an undifferentiated shock patient.
• 3. Describe the management for a patient with septic shock, including IV fluid resuscitation, appropriate antibiotics, and vasopressors.
• 4. Describe the management for a patient in cardiogenic shock, including inotropes, afterload reduction, and diuresis.
• 5. Describe the management for a patient with hemorrhagic shock from an acute gastrointestinal bleed, including volume resuscitation, blood transfusion thresholds, and adjunctive therapies utilized for patients with cirrhosis.
• 6. Identify patients with acute respiratory failure that may benefit from noninvasive positive pressure ventilation.
• 7. Identify indications for intubation and mechanical ventilation.

As described by the core Entrustable Professional Activities (EPAs) outlined by the AAMC, a medical school graduate must be able to “recognize a patient requiring urgent or emergent care and initiate evaluation and management.” 1 Included in the specific functions of this EPA are the abilities to “recognize normal vital signs and variations,” “recognize severity of a patient's illness and indications for escalating care,” and to “start initial care plan for the decompensating patient.” 1 Despite this AAMC recommendation, formalized critical care education during medical school is limited. As of 2015, only 46 of 136 (34%) surveyed medical schools required ICU rotations during a student's fourth year. 2 Furthermore, prior research in student decision-making regarding fourth-year course selection revealed significant fear and anxiety surrounding the choice to pursue an ICU rotation. 3 Regardless of student participation in an ICU course during medical school, a majority of resident physicians are required to care for the critically ill by the ACGME. The six largest residency specialties (internal medicine, family medicine, pediatrics, general surgery, emergency medicine, and anesthesiology) all require residents to provide care for critically ill patients during their training. 4 – 9 In total, the aforementioned groups encompass 64% of all currently practicing residents. 10

At the University of Colorado, similar to the national landscape, there is significant variability in the exposure to formalized critical care education. The University of Colorado internal medicine (IM) third-year clerkship at the Rocky Mountain Regional Veterans Affairs Medical Center (VAMC) provided an opportunity for medical students to rotate through an ICU as part of an open-ICU staffing model. An open-ICU staffing model allows an inpatient medical team to care for patients simultaneously on the floor and in the ICU, as opposed to a closed-ICU model in which critically ill patients are managed exclusively by an intensivist and dedicated ICU service. Prior to March 2019, no structured critical care curriculum existed within the IM clerkship to prepare third-year students for this added ICU experience. Furthermore, a designated ICU course is not a clinical requirement for medical students at our institution. Many medical students miss the opportunity to develop the knowledge and skills necessary to care for the critically ill patient prior to graduation. As currently constructed, the VAMC IM clerkship may represent a student's only formal exposure to critical care medicine prior to residency training.

A needs assessment of students, residents, and faculty at our institution identified a need for increased education in core critical care topics and skills for third-year students during the VAMC IM rotation. Specifically, our assessment highlighted existing skill deficiencies surrounding bedside presentations during ICU teaching rounds, and knowledge gaps regarding support devices, shock, and respiratory failure. Furthermore, there is a paucity of literature describing educational strategies aimed at developing knowledge and skills in critical care targeted toward the third-year medical student. A review of existing resources on MedEdPORTAL utilizing the search terms “critical care” or “ICU” returned 16 results, of which only four resources pertained to medical student education. Three of these student-targeted curricula focused on pediatric critical care, 11 preparation for surgical residency, 12 and palliative care. 13 The most relevant resource published by Luks et al in 2011 described a 10-week course offered to second-year medical students during the preclinical training period. 14 A review of Ovid MEDLINE utilizing the terms “critical care” or “ICU” and “medical student” and “curriculum” yielded no relevant results. To our knowledge, there are no critical care curricula or resources specifically designed for third-year clerkship students available in MedEdPORTAL or in the broader literature.

To address this local and national gap in critical care education, we created an integrated critical care curriculum within the third-year IM clerkship at the VAMC. Our curriculum represents the first integrated critical care resource designed for third-year learners rotating through an IM clerkship with an open ICU. We designed the curriculum as a series of small-group, case-based chalk talks. A chalk talk is an educational format in which an instructor utilizes a whiteboard to convey learning objectives in real time by diagraming key concepts and writing high-yield points. Our primary goal was to improve the student experience during the IM clerkship. Secondary goals included improving attitudes regarding self-perceived confidence in critically ill patient management and objective knowledge of core critical care topics.

Curricular Context

We integrated our curriculum within the third-year IM clerkship at the VAMC site. Third-year medical students rotated at the VAMC for 4-week periods during their IM clerkship. Similar to other VAMCs, our institution's VAMC utilized an open-ICU staffing model. Due to this open-ICU model, the VAMC is the only IM clerkship site at the University of Colorado at which third-year students provided care for critically ill patients.

Implementation

We constructed a seven-session curriculum, delivered twice per week during the first 3 weeks of the students’ VAMC rotation, and once during the fourth and final week. Existing educational commitments limited student availability to 3 afternoons per week during the first 3 weeks, and 2 afternoons during the final week. Consequently, we developed a seven-session curriculum to comply with student availability. We selected topics based on our institution's needs assessment and review of the existing Clerkship Directors in Internal Medicine IM clerkship educational objectives, which required students to care for patients with gastrointestinal (GI) bleeding, heart failure, chronic obstructive pulmonary disease, and sepsis. 15 Our group developed critical care-focused content as a natural extension of these existing objectives. Curriculum sessions occurred in a conference room with a whiteboard and lasted approximately 30 minutes. Second- and third-year IM residents and pulmonary and critical care medicine (PCCM) fellows led curricular sessions. Our curriculum specifically prioritized the participation of residents and fellows as educators in order to increase availability of small-group teaching opportunities during their training.

To ensure facilitator availability for every session, we emailed the dates of teaching sessions to all second- and third-year IM residents rotating at the VAMC 1 week prior to the start of their VAMC rotation. If facilitator spots remained open following this inquiry, we queried IM residents within our institution's clinician-educator pathway or the PCCM fellow at the VAMC. We encouraged facilitators to lead multiple sessions if interested. Notably, this process ensured complete staffing of all sessions throughout the implementation process and created the opportunity for a total of seven different facilitators to participate over a 4-week rotation.

Following the scheduling period, we sent all facilitators the facilitator guide ( Appendix A ). Our group developed this guide in response to student feedback following preliminary implementation to assist facilitators in the creation of their chalk talks while ensuring delivery of key curricular content. The facilitator guide provided a step-by-step walkthrough of each session's educational objectives along with corresponding definitions, clinical examples, and teaching ideas for various learning points. We encouraged facilitators to utilize the guide when preparing for each session.

We introduced the curriculum and provided the syllabus to students via email 1 week prior to the start of their VAMC rotation ( Appendices B and C ). The first session of the curriculum, entitled Introduction to the ICU, occurred on the second day of the 4-week rotation. This session described services provided by the ICU, reviewed illnesses requiring ICU-level care, and demonstrated a systematic approach to bedside ICU rounding presentations. At the conclusion of the session, we provided students a pocket-sized laminated placard entitled ICU Presentation Template ( Appendix D ). The placard served as a quick reference guide for the remainder of the clerkship. At the conclusion of the initial session, students also received the ICU Student Handout, a comprehensive handout with high-yield learning points outlining future sessions ( Appendix E ). We designed the handout as both a reference tool and note-taking template based on student feedback following preliminary implementation.

The second session covered IV access, central venous catheters (CVC), and endotracheal tubes (ETT). During this session, students practiced pushing fluids through peripheral IVs and CVCs to demonstrate Poiseuille's Law. Students also reviewed the parts of an ETT and practiced inflating the cuff of the ETT. The third session defined acute respiratory failure and reviewed indications for noninvasive positive pressure ventilation (NIPPV). During this session, students also reviewed contraindications to NIPPV and indications for endotracheal intubation. The fourth session, entitled Introduction to Shock, defined shock, described clinical manifestations of shock, and provided students with the SHOCK+AWE physical exam-based approach to the undifferentiated shock patient ( Appendix E , page 4). Utilizing the SHOCK+AWE framework, the remainder of the curriculum covered principles of management of septic shock (fifth session), hemorrhagic shock in the context of acute gastrointestinal bleed (sixth session), and cardiogenic shock (seventh session). Facilitators taught all curricular sessions as small-group, case-based chalk talks using the information provided in the facilitator guide ( Appendix A ).

Facilitators and students participated on a voluntary basis. Student participation in our curriculum did not affect clinical grade determination. Our curriculum did not meet the definition for human subject research and, thus, did not require approval by the University of Colorado Institutional Review Board.

We assessed curricular efficacy with regard to medical student attitudes with a novel 13-question end-of-curriculum survey ( Appendix F ). Ten questions assessed level of agreement on a 5-point Likert scale (1 = strongly disagree , 5 = strongly agree ), while three questions allowed for open-ended responses. We constructed the survey to focus on respondent attitudes regarding overall clerkship experience, confidence in critically ill patient management, likelihood of pursuing critical care in the future, and the logistics of curriculum delivery. Following development, we reviewed survey content with medical students that had previously completed the VAMC IM clerkship rotation to determine if questions aligned with student experience and if respondent interpretation of items matched expectations. Educators with experience in curriculum development reviewed the final version of the survey prior to dissemination. Following the final session, students completed the end-of-curriculum survey via Qualtrics, an online survey tool.

Beginning in July 2019, we incorporated pre- and posttests into the curriculum to assess objective knowledge gains of core critical care topics. The 15-question pre- and posttests consisted of nine resident-level questions from the Medical Knowledge Self-Assessment Program and six student-level questions from IM Essentials . 16 , 17 We selected previously published and expert-reviewed content-specific questions to ensure evaluation accuracy. Students completed the pretest on the first day of their rotation following the initial VAMC site orientation. Students completed the posttest following the final curriculum session during the fourth week of their rotation.

Fifty-six third-year medical students rotated through the VAMC from March 2019 to November 2019. An average of five students participated in our curriculum per 4-week clerkship rotation. From July to November 2019, we collected data regarding the total number of curriculum sessions attended by each student. During this time period, 56% of students attended six or seven sessions, 37% attended four or five sessions, and 7% attended two or three sessions. IM residents taught 95% of curriculum sessions. PCCM fellows taught 5% of sessions.

Overall, 41 students (73%) completed the end-of-curriculum survey. Students agreed that their overall clerkship experience improved as a result of our curriculum (73% strongly agree , 24% agree ; Table ). With regard to attitudes, students reported increased comfort in their ability to participate in the management of critically ill patients (44% strongly agree , 51% agree ) as well as increased comfort presenting a patient during teaching rounds in the ICU (41% strongly agree , 41% agree ). Students also reported an increased likelihood of applying for an ICU subinternship during their fourth year of medical school (24% strongly agree , 32% agree ) and a higher likelihood of pursuing a specialty in which they could practice critical care medicine (20% strongly agree , 32% agree ). From a curriculum delivery perspective, students found session topics applicable to their clerkship experience (71% strongly agree , 27% agree ), appropriate in duration (68% strongly agree , 27% agree ), and appropriate for their level of training (73% strongly agree , 24% agree ). Overall, students found protected educational time for our curriculum a valuable part of their clerkship experience (66% strongly agree , 32% agree ).

A thematic analysis of the open-ended response portion of the end-of-curriculum survey revealed the following themes:

• ○ “This material isn't taught anywhere else and it provided a brief review, built on what we know as a framework, and ultimately taught us an outline and approach to management of ICU patients.”
• ○ “Exposure to topics that are not well-covered in medical school didactics.”
• ○ “It was helpful and concise. Explained a lot of concepts I would have otherwise never learned.”
• ○ “Really helped to clarify topics that were frequently confused previously; very helpful for the shelf and moving forward.”
• ○ “The small-group, chalk talk nature. I thought there was a good flow to the series and that each talk built off each other.”
• ○ “The case-based approach was a useful framework for each session.”
• ○ “The small-group nature of the sessions made asking questions comfortable.”
• ○ “Intimate, structured Q&A feel.”
• ○ “I really enjoyed the content and being able to think through concepts as a group.”
• ○ “Excellent teachers; able to connect with [residents] and ask questions without the pressure of rounds/patient care.”
• ○ “I loved the one-on-one interaction with residents…in a low-pressure environment.”
• ○ “Being taught by the residents was great.”
• ○ “Short presentations but very high-yield topics. Loved coming to these sessions.”
• ○ “I enjoyed how efficient these sessions were. They were informative but also quite quick, which made for a great learning opportunity.”
• ○ “Succinct and clear explanations; handouts were fantastic and presented in an easy-to-consume way.”
• ○ “The brevity but clarity was perfect.”
• ○ “Material laid out in a format that helped me organize topics in my mind and was not too in depth or overwhelming.”
• ○ “The organized teaching to our level with diagnosis and management outlines.”

Between July and November 2019, we offered our curriculum to all 32 students that rotated through the VAMC. All 32 students completed the pretest and, of these, 27 (84%) completed the posttest. We utilized posttest completion as a marker of curriculum participation during this time period. Overall, student testing performance improved from a precurricular average of 7.5 (50%) questions correct to a postcurricular average of 10.7 (71%) questions correct (mean improvement of 3.2 questions correct, 21%, p <.0001, CI 2.2–4.4).

An integrated ICU curriculum within the third-year IM clerkship improved the overall clerkship experience for students while providing foundational training and exposure to core topics in critical care medicine. Following curriculum implementation, we observed an improvement in medical student attitudes regarding self-perceived confidence in critically ill patient management, heightened interest in further ICU training, as well as improved objective knowledge. Students found that the small group, chalk talk nature of our curriculum provided the opportunity to learn in a relatively informal, low-pressure situation compared to typical bedside ICU teaching rounds. In addition, students consistently and overwhelmingly agreed that our curriculum provided applicable, efficient, and appropriate content for their level of training. Ultimately, our novel curriculum demonstrated that it was both feasible and beneficial to provide students with an early introduction to critical care medicine while rotating through an IM clerkship site that utilizes an open-ICU staffing model.

Students emphasized the importance of residents as educators during the IM clerkship. Our curriculum created seven unique teaching opportunities per 4-week rotation for IM residents and PCCM fellows to practice chalk talk delivery, develop small-group facilitation skills, and gain experience as educators. In addition, our curriculum allowed residents in our institution's clinician-educator pathway to gain valuable, hands-on teaching experience.

Scheduling of sessions and facilitators proved to be one of the more difficult aspects of implementation. After trialing several time slots, we found session attendance highest on Monday and Tuesday afternoons. We also found greater success scheduling facilitators if we reached out 1 week prior to the first curriculum session. Ultimately, many facilitators expressed interest in leading multiple sessions, which improved rapport and engagement with students. For future groups interested in implementing our curriculum, we recommend establishing a curriculum coordinator role for one to three IM residents. Coordinator responsibilities would include facilitator scheduling, communicating with students, and collecting evaluation materials.

Our curriculum had several limitations. The curriculum was designed for incorporation into IM clerkships with access to an open ICU. We recognize that the majority of academic medical centers employ a closed-ICU model that typically precludes ICU exposure for third-year students on non-ICU rotations. A significant number of medical schools utilize VAMCs as a clinical site for at least part of the IM clerkship. VAMCs commonly employ an open-ICU staffing model offering the opportunity for the widespread application of our curriculum. The subject content and educational strategies of our curriculum could similarly be applied during a dedicated ICU rotation. Our curriculum objectives focused on knowledge acquisition of core critical care topics and development of skills to improve bedside rounding presentations. Our evaluation methods predominantly captured attitudes and perceptions of the learner. We created the pre- and posttest to address this limitation, but only applied the testing component to students who participated in the curriculum from July to November 2019. As currently constructed, we cannot determine whether the benefits of our curriculum translated to student performance improvement during the IM clerkship, as our evaluation methods focused solely on attitudes and knowledge. We intend to address this limitation by modifying our current evaluation strategy to include direct observation of bedside presentations and simulation performance. Improvements in medical student attitudes and knowledge may be confounded by the maturation effect associated with rotating through an open ICU for a 4-week period. This limitation could be addressed in the future by utilizing a control group at an IM clerkship site without ICU exposure. Finally, our knowledge assessment tool utilized previously published questions, limiting the generalizability due to copyright protections.

Since implementation in March 2019, we fully incorporated our curriculum into the framework of the third-year IM clerkship rotation at the VAMC site. Our curriculum improved the overall clerkship experience while positively impacting both attitudes and knowledge of critical care medicine. Future directions include utilizing the chalk talks as primers for high-fidelity simulation scenarios, as well as creating electronic learning content such as videos to promote wider dissemination and a flipped classroom approach. We also intend to collect data from prior student participants to determine whether our curriculum ultimately affected decisions to pursue ICU rotations during their fourth-year or impacted their choice of career specialty. Overall, our integrated critical care curriculum is the first resource specifically designed to maximize the benefits of an open ICU for third-year learners and represents one possible avenue for addressing both local and national gaps in critical care education prior to residency training.

Disclosures

None to report.

Funding/Support

Prior presentations.

Gergen D, Raines J, Lublin B, Neumeier A, King C. Developing an integrated critical care curriculum within the third-year internal medicine clerkship. Poster presented at 2020 American Thoracic Society International Conference (Virtual). May 17, 2020; Philadelphia, PA.

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Infection Control Basics

• Infection control prevents or stops the spread of infections in healthcare settings.
• Healthcare workers can reduce the risk of healthcare-associated infections and protect themselves, patients and visitors by following CDC guidelines.

Germs are a part of everyday life. Germs live in our air, soil, water and in and on our bodies. Some germs are helpful, others are harmful.

An infection occurs when germs enter the body, increase in number and the body reacts. Only a small portion of germs can cause infection.

Terms to know

• Sources : places where infectious agents (germs) live (e.g., sinks, surfaces, human skin). Sources are also called reservoirs.
• Susceptible person: someone who is not vaccinated or otherwise immune. For example, a person with a weakened immune system who has a way for the germs to enter the body.
• Transmission: a way germs move to the susceptible person. Germs depend on people, the environment and/or medical equipment to move in healthcare settings. Transmission is also called a pathway.
• Colonization: when someone has germs on or in their body but does not have symptoms of an infection. Colonized people can still transmit the germs they carry.

For an infection to occur, germs must transmit to a person from a source, enter their body, invade tissues, multiply and cause a reaction.

How it works in healthcare settings

Sources can be:.

• People such as patients, healthcare workers and visitors.
• Dry surfaces in patient care areas such as bed rails, medical equipment, countertops and tables).
• Wet surfaces, moist environments and biofilms (collections of microorganisms that stick to each other and surfaces in moist environments, like the insides of pipes).
• Cooling towers, faucets and sinks, and equipment such as ventilators.
• Indwelling medical devices such as catheters and IV lines.
• Dust or decaying debris such as construction dust or wet materials from water leaks.

Transmission can happen through activities such as:

• Physical contact, like when a healthcare provider touches medical equipment that has germs on it and then touches a patient before cleaning their hands.
• Sprays and splashes when an infected person coughs or sneezes. This creates droplets containing the germs, and the droplets land on a person's eyes, nose or mouth.
• Inhalation when infected patients cough or talk, or construction zones kick up dirt and dust containing germs, which another person breathes in.
• Sharps injuries such as when someone is accidentally stuck with a used needle.

A person can become more susceptible to infection when:

• They have underlying medical conditions such as diabetes, cancer or organ transplantation. These can decrease the immune system's ability to fight infection.
• They take medications such as antibiotics, steroids and certain cancer fighting medications. These can decrease the body's ability to fight infection.
• They receive treatments or procedures such as urinary catheters, tubes and surgery, which can provide additional ways for germs to enter the body.

Recommendations

Healthcare providers.

Healthcare providers can perform basic infection prevention measures to prevent infection.

There are 2 tiers of recommended precautions to prevent the spread of infections in healthcare settings:

• Standard Precautions , used for all patient care.
• Transmission-based Precautions , used for patients who may be infected or colonized with certain germs.

There are also transmission- and germ-specific guidelines providers can follow to prevent transmission and healthcare-associated infections from happening.

Learn more about how to protect yourself from infections in healthcare settings.

For healthcare providers and settings

• Project Firstline : infection control education for all frontline healthcare workers.
• Infection prevention, control and response resources for outbreak investigations, the infection control assessment and response (ICAR) tool and more.
• Infection control specifically for surfaces and water management programs in healthcare settings.
• Preventing multi-drug resistant organisms (MDROs).

Infection Control

CDC provides information on infection control and clinical safety to help reduce the risk of infections among healthcare workers, patients, and visitors.

For Everyone

Health care providers, public health.