Burn Shock and Resuscitation: Many Priorities, One Goal

Burn injuries come in a wide variety of presentations, depending on the size and depth of the thermal insult, concurrent traumatic or inhalation injury, as well as the associated physiological response of the burn victim. To minimize patient morbidity and reduce mortality, prompt recognition and tailored treatment strategies are critically important. As the percentage of total body surface area (TBSA) burned increases so do the body’s physiologic response and the associated complexity of management. Understanding the pathophysiology of burn injury allows the practitioner to optimize and individualize burn patient management—a component of care critical to limiting wound progression and improving outcomes. Burn patient care starts with an accurate and thorough burn patient evaluation conducted in person by an experienced provider. For burns >10–15% TBSA, prompt initiation of fluid resuscitation greatly impacts clinical outcomes. Several formulae have been published to guide crystalloid and/or colloid fluid resuscitation in the setting of burn shock. Other important considerations include ambient temperature control, early enteral nutritional support, vitamin and mineral supplementation, assessment for inhalation injury, glycemic control, early recognition of potential complications of large volume resuscitation, potential need for cardiovascular support, and early wound excision and coverage. Burn patients often require multidisciplinary teams to manage the physical, social, and psychological effects associated with their injury. Dedicated burn centers are the ideal places for meeting the complex needs of each burn patient

The Role of Biosurgical Hemostatic Sealants in Cardiac Surgery

The focus on superb quality and value of medical and surgical care has become a cornerstone of modern clinical practice. Within the realm of cardiothoracic surgery, quality is synonymous with technically excellent, safely conducted operative procedure followed by an uneventful patient recovery and follow-up. Critical to this process of clinical value creation is meticulous attention to all aspects of every step along the management continuum. From surgical quality improvement perspective, the reduction in blood loss and thus minimization of blood/blood product transfusions are of critical importance. This chapter focuses on the role of biosurgicals as useful adjuncts to achieving the ultimate goal of uneventful cardiac procedure and thus set the patient’s clinical course for optimal postoperative recovery and long-term well-being

Combating Alarm Fatigue: The Quest for More Accurate and Safer Clinical Monitoring Equipment

As the demand for health-care services continues to increase, clinically efficient and cost-effective patient monitoring takes on a critically important role. Key considerations inherent to this area of concern include patient safety, reliability, ease of use, and cost containment. Unfortunately, even the most modern patient monitoring systems carry significant drawbacks that limit their effectiveness and/or applicability. Major opportunities for improvement in both equipment design and monitor utilization have been identified, including the presence of excessive false and nuisance alarms. When poorly optimized, clinical alarm activity can affect patient safety and may have a negative impact on care providers, leading to inappropriate alarm response time due to the so-called alarm fatigue (AF). Ultimately, consequences of AF include missed alerts of clinical significance, with substantial risk for patient harm and potentially fatal outcomes. Targeted quality improvement initiatives and staff training, as well as the proactive incorporation of technological improvements, are the best approaches to address key barriers to the optimal utilization of clinical alarms, AF reduction, better patient care, and improved provider job satisfaction

Septic Embolism in Endocarditis: Anatomic and Pathophysiologic Considerations

Septic embolism is a relatively common and potentially severe complication of infective endocarditis (IE). Septic emboli (SE), most often described as consisting of a combination of thrombus and infectious material—either bacterial or fungal—can be caused by hematogenous spread from virtually any anatomic site; however, it most commonly originates from cardiac valves. During the past two decades there has been a confluence of various risk factors that, both alone and in combination, led to greater incidence of both IE and SE, including increasing population age, greater use of prosthetic valves, implantation of various intracardiac devices, escalating intravenous drug use, and the high incidence of healthcare associated infections with antibiotic resistant microorganisms. From a clinical standpoint, SE can present at any time during the course of IE and may even be the initial presenting sign. SE may affect virtually any location in the human body, but some organs (e.g., liver, spleen, brain) and anatomic regions (e.g., lower extremity) tend to be more frequently involved. The most important aspect of management involves prompt recognition and proactive therapeutic approach. Given the broad spectrum of clinical presentations, symptoms and complications, SE can be challenging to diagnose and treat. Following the identification of SE, appropriate antibiotic coverage should be immediately instituted followed by supportive and/or interventional management, depending on the severity of presentation and the associated complications. In this chapter we explore the pathophysiology, anatomic origins, diagnostic tools, therapeutic measures, and new developments in SE, focusing predominantly on bacterial infections of cardiac origin

Coronary Embolic Phenomena: High-Impact, Low-Frequency Events

Coronary embolic phenomena (CEP) are difficult to diagnose yet carry potentially devastating clinical consequences. The goal of this chapter is to outline key processes and pathophysiologic mechanisms underlying CEP, primarily in the context of acute coronary syndrome (ACS). Not surprisingly, most reported cases of CEP occur in the left coronary circulation, but some right-sided events have been reported. Overall, causes include thrombotic, septic/infectious, neoplastic, valve-related, and iatrogenic mechanisms such as air embolization. Coronary angiography remains the definitive diagnostic and therapeutic approach, with computed tomography being increasingly utilized. Transthoracic echocardiography (TTE) should be part of a routine work up for patients with suspected CEP. Holter/event monitoring for atrial fibrillation may also be indicated in patients with embolic phenomena. Clinical management includes procedural restoration of coronary blood flow, followed by appropriate anticoagulation or antiplatelet therapy, in conjunction with appropriate treatment of any arrhythmias or other associated cardiac manifestations or conditions. Timely diagnosis, based on a high index of suspicion (especially in high-risk population) may be important in improving morbidity and mortality in affected patients. Since CEPs are often underdiagnosed and may be due to a number of heterogeneous causes, the need arises for increasing provider awareness of these important phenomena, as well as for the implementation of appropriate clinical management guidelines

Exposure Keratopathy in the Intensive Care Unit: Do Not Neglect the Unseen

Exposure keratopathy (EK) is a frequently overlooked complication seen in nearly 60% of sedated or intubated intensive care unit (ICU) patients. Signs and symptoms of EK often start as mild subjective complaints of eye pain and irritation, but can progress to vision loss in the most severe cases. For many critically ill patients, the presence of sedation effectively precludes their ability to communicate clinical complaints typically associated with EK. This, combined with the potentially severe sequelae, makes EK a potentially preventable complication and a patient safety issue. Clinical management of EK can be challenging for both providers and patients due to the nature of treatment with eye drops and ointments as well as the burden and expense of associated procedural interventions. Risk factors for EK have been extensively described in the literature, and wider dissemination of this knowledge should facilitate education of physicians and nurses regarding EK prevention. The most common risk factors include lagophthalmos, chemosis, Bell’s palsy, and congenital deformities. Additionally, critically ill patients are less likely to be promptly diagnosed due to the focus of staff on life-threatening problems over ocular prophylaxis. However, the potential severity of complications associated with EK mandates that prevention remains a crucial component of the care of at-risk patients. The reader will explore the broad category of adverse medical occurrences included under the umbrella term, “errors of omission” (EOO): an error category that is most likely to culminate in EK. The most critical preventive measure is education of health care providers, although this may not be enough by itself. To this end, universal precautions against EK in combination with education may be used to help combat the relatively high incidence of this easily preventable ocular pathology