Echocardiography in acute critical care in cardiology

Diagnostic opportunities of echocardiography in the acute cardiac care are reviewed. It is shown in detail how to perform echocardiography in different scenarios of critical conditions, especially in acute chest pain, acute hypotension and shock, in acute dyspnoea, in chest trauma, in post-procedural and post-surgical complications. The advantages and disadvantages of the echocardiographic method in acute myocardial infarction with complications, in acute aortic dissection, in cardiac tamponade, in pulmonary embolism, in systolic left ventricular dysfunction and in acute valvular dysfunction are analyzed. Key words: critical care, echocardiography, dyspnoea, shock, chest pain, tamponade, pulmonary embolism, aortic dissection.

Controversies in Sepsis Management—What is the Way Forward?

Sepsis is life-threatening and might potentially progress from dysregulation to severe organ dysfunction. It is recognised by the World Health Organisation as a global health priority. The mortality rate for sepsis has decreased in many countries, and this is credited to the earlier recognition and treatment of this complex syndrome. In 2002, the Surviving Sepsis Campaign was launched, and there have been several revisions to the sepsis recommendations therefrom. The latest sepsis guidelines focus on viral as well as bacterial infections, and advise that initiating resuscitation and management should take place within one hour from when sepsis is initially suspected. Numerous studies and guidelines pertaining to sepsis management have been published over the past 2 decades. The use of novel therapies and alternative adjunctive therapies has tremendous potential in sepsis management. Debates amongst intensivists exist with the creation of updated sepsis guidelines and advances in treatment. The present review article provides both a summary and recommendations based on the latest clinical evidence and controversies around sepsis management. Key words: Critical Care Medicine, Intensive Care Medicine, Respiratory Medicine, Sepsis, Sepsis Bundles, Sepsis Management

Controversies in Sepsis Management—What is the Way Forward?

Sepsis is life-threatening and might potentially progress from dysregulation to severe organ dysfunction. It is recognised by the World Health Organisation as a global health priority. The mortality rate for sepsis has decreased in many countries, and this is credited to the earlier recognition and treatment of this complex syndrome. In 2002, the Surviving Sepsis Campaign was launched, and there have been several revisions to the sepsis recommendations therefrom. The latest sepsis guidelines focus on viral as well as bacterial infections, and advise that initiating resuscitation and management should take place within one hour from when sepsis is initially suspected. Numerous studies and guidelines pertaining to sepsis management have been published over the past 2 decades. The use of novel therapies and alternative adjunctive therapies has tremendous potential in sepsis management. Debates amongst intensivists exist with the creation of updated sepsis guidelines and advances in treatment. The present review article provides both a summary and recommendations based on the latest clinical evidence and controversies around sepsis management. Key words: Critical Care Medicine, Intensive Care Medicine, Respiratory Medicine, Sepsis, Sepsis Bundles, Sepsis Management

How to Feed the Critically Ill—A Review

Introduction: Number of recently published studies on nutritional support in the intensive care unit (ICU) have resulted in a paradigm shift of clinical practices. This review summarises the latest evidence in four main topics in the ICU, namely: (1) function of validated nutrition screening/assessment tools, (2) types and validity of body composition measurements, (3) optimal energy and protein goals, and (4) delivery methods. Methods: Recent studies that investigated the above aims were outlined and discussed. In addition, recent guidelines were also compared to highlight the similarities and differences in their approach to the nutrition support of critically ill patients. Results: Regardless of nutritional status and body composition, all patients with >48 hours of ICU stay are at nutrition risk and should receive individualised nutrition support. Although a recent trial did not demonstrate an advantage of indirect calorimetry over predictive equations, it was recommended that indirect calorimetry be used to set energy targets with better accuracy. Initiation of enteral nutrition (EN) within 24–48 hours was shown to be associated with improved clinical outcomes. The energy and protein goals should be achieved gradually over the first week of ICU stay. This practice should be protocolised and regularly audited as critically ill patients receive only part of their energy and protein goals. Conclusions: Metabolic demands of critically ill patients can be variable and nutrition support should be tailored to each patient. Given that many nutrition studies are on-going, we anticipate improvements in the individualisation of nutrition support in the near future. Key words: Critical care, Critical illness, Intensive care, Nutrition, Nutritional intake, Nutrition support

Postoperative Management of Liver Transplant Patients

Management of the postoperative liver transplant patient can be extremely challenging. The combination of preoperative comorbidities and intraoperative complexity can make for a tenuous postoperative critical care course. Consideration and monitoring of graft function are paramount as poor graft function or primary graft nonfunction will affect every aspect of care. Our goal in this review is to use a systems-based approach to highlight the key tenets for postoperative management of liver transplant patients to help orchestrate integrated care across subspecialties. This review contains 2 figures, 2 tables, and 94 references. Key words: critical care, liver transplant, systems-based management

Postoperative Management of Liver Transplant Patients

Management of the postoperative liver transplant patient can be extremely challenging. The combination of preoperative comorbidities and intraoperative complexity can make for a tenuous postoperative critical care course. Consideration and monitoring of graft function are paramount as poor graft function or primary graft nonfunction will affect every aspect of care. Our goal in this review is to use a systems-based approach to highlight the key tenets for postoperative management of liver transplant patients to help orchestrate integrated care across subspecialties. This review contains 2 figures, 2 tables, and 94 references. Key words: critical care, liver transplant, systems-based management

Coding and Billing

Appropriate documentation and coding are critical for billing in the intensive care unit (ICU). Diagnoses are based on the International Statistical Classification of Diseases and Related Health Problems (e.g., ICD-9 or ICD-10). Procedures are coded based on the Current Procedural Terminology (CPT) system. Evaluation and management (E/M) services make up the vast majority of non–procedure-based care provided by physicians in the ICU environment. Critical care services (codes 99291 and 99292) represent a specific subset of the CPT codes for E/M with different requirements. Three criteria must be met to justify a critical care code. First, the physician must document that the patient is critically ill (i.e., the patient has impairment in one or more vital organ systems with a high probability of imminent or life-threatening deterioration). Second, critical care requires high-complexity medical decision making to support vital organ function and/or prevent further deterioration. Third, critical care codes are time based. The physician must document the time spent in “full attention” to the patient. Critical care can also be provided via telemedicine technologies. Reimbursement for these services requires appropriate credentialing and contracts with the hospital, as well as appropriate documentation. Hospital reimbursement is based on Medical Severity-Diagnosis Related Groups (MS-DRGs), as documented in the medical record. Based on performance, a portion of hospital reimbursement may be withheld if the rates for certain hospital-acquired conditions are too high. Accurate documentation serves to (1) provide good communication between providers, (2) justify billing, and (3) legally document what was done for the patient and why. This review contains 4 tables, and 13 references. Key words: critical care codes, evaluation and management codes, global surgical package, pay for performance