Articles from Critical Care Medicine

Link to journal online
Greer, David M. MD, MA
Multimodal magnetic resonance imaging for determining prognosis in patients with traumatic brain injury-Promising but not ready for primetime .[Editorial]
Critical Care Medicine. 37(4):1523-1524, April 2009.

Baker, Stephen MD, MPH
Trauma computed tomography and radiation dose: A matter of concern .[Editorial]
Critical Care Medicine. 37(4):1508-1509, April 2009.

Salottolo, Kristin MPH; Bar-Or, Raphael BS; Fleishman, Matthew MD; Maruyama, Gen et al
Current utilization and radiation dose from computed tomography in patients with trauma .[Article]
Critical Care Medicine. 37(4):1336-1340, April 2009.
Abstract
Objective: To quantify the cumulative effective dose of radiation received during hospitalization after traumatic injury and to compare the computed tomography (CT) utilization practices for two time periods in patients with trauma.Design: A retrospective analysis of radiologic and medical data.Setting: A level I trauma center.Patients: Consecutively admitted adult patients with trauma with moderate to severe injuries (injury severity score >8), an intensive care unit (ICU) length of stay of one or more days, who were directly admitted and not transferred to another acute care center.Measurements and Main Results: CT examination means and utilization were compared for April through August, 2003 and April to August, 2007. Cumulative effective doses were calculated for the 2007 period, and patients with a high radiation dose (>100 mSv) were identified. One hundred sixty-five adult patients with trauma were included. An increase in mean CT examinations per patient was observed in the 2007 period compared with the 2003 period, overall (4.41 vs. 3.44, p = 0.002) and among subsets of patients. The overall increase remained significant after adjustment for patient demographics (p = 0.05). The mean cumulative effective dose per patient was 11.13 mSv in 2007; 9% of patients received a dose >=100 mSv.Conclusions: Patients with trauma are at an increased risk of adverse effects from CT studies, because they receive high doses of radiation, and the number of CT examinations that patients receive is increasing with time. We recommend that risk of radiation be prospectively monitored and estimated by hospitals through the use of CT examination count per patient.

Schweickert, William D. MD; Herlitz, Jean RN; Pohlman, Anne S. ; Gehlbach, Brian K. et al
A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures.
Source Critical Care Medicine. 37(4):1217-1221, April 2009.
Abstract Objective: Insertion of peripherally inserted central catheters (PICCs) at the bedside may result in tip malposition. This study was designed to evaluate whether the addition of ultrasound (US) inspection of the ipsilateral neck provides immediate recognition of PICCs in aberrant position facilitating catheter reposition before completion of the procedure.
Design: Randomized, controlled trial.Setting: University-affiliated hospital.Patients: Totally, 300 patients ordered for PICC placement.Interventions: Patients were randomized to either postinsertion US inspection of the ipsilateral neck (intervention, n = 151) or to usual practice (control, n = 149). In the intervention group, catheters detected by US to be traveling within the ipsilateral internal jugular vein (IJ), were further adjusted before procedural completion. All procedures included US localization of the peripheral vein and postprocedural chest radiograph to assess catheter tip position. The primary end point was defined as the rate of PICC tip malposition in the ipsilateral IJ as detected by postprocedure chest radiograph. The secondary end point was procedure duration.
Measurements and Main Results: In the control arm, 140 of 149 PICC placement attempts (94%) were completed, including 11 procedures with catheter tips terminating in the ipsilateral IJ (7.9%). In the intervention arm, 142 of 151 attempts (94.7%, p = 0.98) were completed; one procedure resulted in a catheter tip in the ipsilateral IJ (0.7%, p = 0.007). Eleven intervention procedures included successful PICC repositioning during the initial procedure based on US detection of malposition. The median duration of the procedure in the control group was 8 minutes (6-10.5 minutes) and increased to 9.0 minutes (7-11 minutes) in the intervention group.
Conclusions: Bedside PICC placement morbidity can be reduced via US inspection of the ipsilateral neck for PICC tip malposition in the IJ. This modality can guide catheters to be successfully repositioned during the initial procedure.