iPad hands on review: Fits in your white coat and is fast enough for Medical point of care use [Healthcare Perspective]

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It really starts with you. As taboo as the topic may be, its a must for every individual to think about this and most importantly discuss it with the ones you love most. This is the most effective way to ensure that your wishes are truly upheld.

Here’s a great tool available online – The One Slide Project

Here is a link to the US Living Will Registry where you can find out more specific information. The link takes you directly to the state specific forms.

Several measures of ICU performance have been proposed in the past 30 years. It is intuitive, and correct, to assume that ICU mortality may be a useful marker of quality. However, crude mortality rates does not take into consideration the singular aspects of each specific patient population that is treated in a certain geographic region, hospital or ICU. Therefore approaches looking for standardized mortality ratios that are adjusted for disease severity, comorbidities and other clinical aspects are often sought. Severity of illness is usually evaluated by scoring systems that integrates clinical, physiologic and demographic variables. Scoring systems are interesting tools to describe ICU populations and explain their different outcomes. The most frequently used are the APACHE II, SAPS II and MPM. However, newer scores as APACHE IV and SAPS III have been recently introduced in clinical practice. More than only using scoring systems, one should search for a high rate of adherence to clinically effective interventions. Adherence to interventions as deep venous thrombosis prophylaxis, reduction of ICU-acquired infections, adequate sedation regimens and decreasing and reporting serious adverse events are essential and have been accepted as benchmarking of quality.

The complex task of collecting and analyzing data on performance measures are made easier when clinical information systems are available. Although several clinical information systems focus on important aspects as computerized physician order entry systems and individual patient tracking information, few have attempted to gather clinical information generating full reports that provide a panorama of the ICU performance and detailed data on several domains as mortality, length of stay, severity of illness, clinical scores, nosocomial infections, adverse events and adherence to good clinical practice. Through implementing quality initiatives, increasing the quality of care and patient safety are major and feasible goals. Such systems are available for clinical use and may facilitate the process of care on a daily basis and provide data for an in-depth analysis of ICU performance.

FDA’s anesthesiology and respiratory therapy devices advisory committee will meet May 28 in Gaithersburg, Md., to discuss Johnson & Johnson/Ethicon Endo-Surgery’s pre-market approval application for its Sedasys computer-assisted personalized sedation system, indicated for minimal to moderate sedation in adult patients undergoing colonoscopy and esophagogastroduodenoscopy procedures.

This is certainly going to spark some fireworks on both sides of the court. Can this really replace anesthesiologist presence in the GI suite? Lets see what the FDA has to say. In my opinion, we should certainly not jump to quick legislation and really put patient safety at the forefront! Just because it can be done DOESN’T mean it should be done.

Here is information about this controversial and potentially game changing technolology from JnJ.

Ethicon Endo-Surgery announced that the results from its pivotal trial demonstrated physician/nurse teams using the SEDASYS™ System reduced the risk of over sedation with propofol in patients undergoing screening and diagnostic procedures for colorectal cancer (colonoscopy), and disorders of the upper gastrointestinal tract (EGD). The study [...] included 1,000 subjects who underwent sedation for colonoscopy and EGD at eight sites and compared the SEDASYS™ System to the current standard of care for sedation (midazolam plus fentanyl or meperidine). Results were included in Ethicon Endo-Surgery’s PreMarket Application (PMA) for approval of the SEDASYS™ System, which is currently in review with the U.S. Food and Drug Administration.

“During the trial, the system made it possible for gastroenterologists to maintain minimal to moderate sedation with propofol, and helped prevent patients from entering deep sedation, which is traditionally associated with propofol,” said Daniel Pambianco, MD, F.A.C.G., medical director of Charlottesville (Va.) Medical Research and trial investigator. “The system offers a way to personalize the level of sedation appropriate for each patient because it combines propofol delivery with sophisticated monitoring to help us better control and predict the patient’s sedation level.”

Patients who received sedation with the SEDASYS™ System experienced fewer and less significant oxygen desaturation events, a clinical sign of over sedation, than patients sedated with current standard of care. The trial demonstrated this by achieving its primary endpoint of Area Under the Curve (AUC) of oxygen desaturation (SpO2 < 90%). AUC is an objective measure of a patient’s respiratory status that incorporates incidence, duration and depth of oxygen desaturation. Patients in the SEDASYS™ System group had an average AUC value of one-third less than the current standard of care patients. No device-related adverse events occurred in patients sedated with the SEDASYS™ System.

SEDASYS™ System patients were minimally-to-moderately sedated with propofol during the study. Sedation level was assessed every two minutes using a Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) scale of 0-5. Patients who are minimally sedated respond readily when called by name (MOAA/S=5), while moderately sedated patients may require mild tactile stimulus to respond (MOAA/S=2-4). More than 99 percent of SEDASYS™ System patient responses were a MOAA/S score of 2 – 5, indicating minimal to moderate sedation.

(excerpt from may 2008 taken from)
Johnson and Johnson
http://www.jnj.com

List of Useful Resources:

American Society of Anesthesiology:

• Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia – 2004
• Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists, 2002
• Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals – 2006
• Granting Privileges to Non-Anesthesiologist Practitioners for Personally Administering Deep Sedation or Supervising Deep Sedation by Individuals Who Are Not Anesthesia Professionals, Statement on — 2006

Ohio Board of Nursing

• State of Ohio Board of Nursing: Guidelines for Administration of Medications, and Monitoring of Patients Receiving Intravenous Moderate Sedation for Medical/Surgical Procedures, July 20, 2007

ACG (American College of Gastroenterology) Practice Guidelines

• ACG Practice Guidelines

ASGE (American Society for Gastrointestinal Endoscopy) Practice Guidelines

• ASGE Practice Guidelines

Her is a presentation that goes over what my vision is for the “FUTURE ICU.” I originally presented this about a year ago during my fellowship. Enjoy!

There are several societies, publications, interest groups dedicated to patients suffering from ESLD in need of liver transplantation. One of the most respected of those is the Americal Association for the Study of Liver Disorders. They publish Hepatology and  Liver Transplantation and have an excellent website  for review of recent updates on these topics. In june 2005 they published a thorough set of guidelines entitled “Evaluation of a Patient for Liver Transplantation.”  This is an excellent resource and reviews the most recent recommendations regarding the pre-operative workup of patients undergoing a Liver transplant and any provides evidence based medicine guidelines for clearance of surgery. To the best of my knowledge these are the most recent guidelines published in the literature as of today.

Upon searching the web, I found another excellent resource of narrated powerpoint lectures co-sponsored by AASLD, International Liver Transplantation Society (ILTS) and The Americal Society of Transplantation(ATS). You can watch the presentations here.

Up next, stay tuned for the EXPANDED CRITERIA discussion….

This has been a hot topic surrounding not only the transplant community but also the critical care and anesthesia world. It is not uncommon for Dr. Sanjay Gupta or Dr. Oz (the premier TV celebrity docs) to come on national television usually on major broadcast shows such as Oprah and describe fantastic success stories that describe recent transplanted patient’s lives. Of course it is great that these patients did well, but this doesn’t mean they ALL do well!! This is certainly evidenced by some of the “expanded” criteria patients we take care of in the ICU.

Certainly we should be doing our best to give as many patient’s a chance at a new life – at a new liver. But the patient’s need to be better informed of the risks and alternatives and given realistic expectations. “Mr. Patient it isn’t gonna be like Dr. Gupta described – you won’t be as lucky but don’t worry you will have a new LIVER.”. Sometimes they might choose a shorter survival when faced with near definitive trach/dialysis/nursing home or chronic vent support situation that many of the high risk patients face today. It isn’t all about 28 and 90 day mortality rates! It should be about QUALITY OF LIFE.

November WSJ article was an excellent look at the exact phenomenon. Take a look at it here
“DOING A VOLUME BUSINESS IN LIVER TRANSPLANTS”

So the next couple of posts will be dedicated to revisiting the criteria for liver transplant and a detailed look at the “Expanded” criteria opened up for high risk patients to increase recruitment of potential recipients. Let us see if this is really for the patient’s or for numbers of the transplant center. Stay Tuned!

The Endocrine Society is an multi-national, multidiscipline organization with ~14,000 members from over 100 countries. It was founded in 1916 and publishes 4 peer-reviewed journals. On March 26th, 2009 immediately after the NICE SUGAR study was published they released a statement which supports loosening glycemic control in ICU patients may now be more prudent.  They state that we should be targeting glucose values between 144-180 mg/dl “until we better understand the reasons for these somewhat counterintuitive findings.”
Below is an excerpt from the statement which can be viewed in its entirety here   –>

The Endocrine Society commends the NICE-SUGAR investigators for producing an important and provocative addition to the medical literature and draws the following conclusions and recommendations from their data. First, near-normalization of blood sugar does not clearly improve outcomes in all critically ill hyperglycemic ICU patients, and there is even a suggestion that such an approach may worsen outcomes. Second, looser control of hyperglycemia, i.e., target blood glucose of 144-180 mg/dl, is a reasonable, and perhaps preferable, option in this particular group of very sick patients. Third, it is essential to assess clinically meaningful outcomes, such as mortality, as well as surrogate or intermediate endpoints, such as blood sugar level, in studies of diabetes treatment as the NICE-SUGAR study has done; improvement of blood sugar control may not always translate to better clinical results.