Society of Critical Care Anesthesiologists

S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S Volume 2524 Number 15 WinterWinter 20132014 www.SOCCA.org

President’s Column: SOCCA and Strategic The overall structure of the 27th Annual One of the reasons SOCCA chose to partner Meeting and Critical Care Update will remain with IARS is because the strategic vision of Partnership With IARS as one entire day of educational opportunities SOCCA is supported by IARS. This includes the presented with the highest quality, as has been plan for SOCCA to increase its membership, its tradition. The submission of competitive especially with those who are interested in abstracts with high-caliber presentations will future careers in critical care . remain a key feature of the SOCCA meeting. We at SOCCA would like to include medical Please watch for updates in future newsletters students, residents, and critical care fellows and begin preparing your abstracts, as there as members, with their ability to learn from the will be earlier submission dates this year for educational opportunities and mentorship from these scholarly presentations because of the other SOCCA members. SOCCA is developing May meeting time. The SOCCA ultrasound an updated “Residents’ Guide,” with a projected workshop will now be offered as a several- release in 2014.

Please join us in Montréal, Canada for the 27TH SOCCA Annual Meeting and Critical Care Update Brenda G. Fahy, M.D., F.C.C.M. on Friday, May 16, 2014. We have an exciting program planned for you at the upcoming SOCCA meeting. The SOCCA 26th Annual Meeting and Critical Care Update hour workshop during the IARS meeting. For SOCCA looks forward to this partnership at the American Society of Anesthesiologists the convenience of SOCCA attendees, this with IARS and we are excited at the wonderful annual meeting in San Francisco last October is planned to occur the day after the SOCCA opportunities and the potential international was a great success. The educational program meeting. Other workshop opportunities SOCCA collaboration that the International provided a depth of topics, and many residents will offer include an anesthesia-oriented Research Society will afford SOCCA. Please were attracted to the mentoring program. As ACLS course. SOCCA membership has had join us in Montréal – first for the SOCCA 27th discussed at the business meeting, SOCCA is input into the IARS program for Montréal and Annual Meeting and Critical Care Update, and proceeding with a strategic alliance with the will participate in other educational offerings, then stay for the IARS Annual Meeting. International Anesthesia Research Society including lectures, panels and Problem- Hope to see you there, or as they say in (IARS), which will officially begin on January 1, Based Learning Discussions. Please join the Montréal, “Au plaisir de vous y voir!“ 2014. The annual meeting of SOCCA will, for the SOCCA and IARS activities in Montréal this next two years, occur immediately preceding coming May. The final program will be posted the IARS Annual Meeting. For 2014, the all- soon, so watch for it on the IARS website day SOCCA Annual Meeting and Critical Care www.iars.org/home/default.asp or as Update will take place on May 16 in Montréal. advertised in Anesthesia & Analgesia.

ANESTHESIA & ANALGESIA is the Official Journal of SOCCA S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

CONTENTS SOCCA 26th Annual Meeting Recap ...... 3 Barrier Precaution Recommendations for Arterial Line Placement ...... 8

PRO: Utilization of Invasive Arterial Emergency ACCM Training ...... 11 int he Critically Ill ...... 6

Fellowship Program Directors Breakfast Summary ...... 13 CON: Utilization of Invasive Arterial Blood Pressure Monitoring int he Critically Ill ...... 7 Fellowship Review: The University of California, San Francisco (UCSF) ...... 14

MEMBERSHIP INFORMATION E-mail Membership SOCCA Dues You may e-mail inquiries to SOCCA at: Membership in SOCCA is open to all Dues are $150 for active members; $100 for General inquiries: anesthesiologists and residents in approved affiliate members and $20 for residents/fellows. [email protected] anesthesiology programs. Membership applications Dues may be paid online at www.SOCCA.org/ Meeting information: may be obtained by contacting SOCCA at membership.php by credit card or by mailing [email protected] (847) 825-5586 or through the SOCCA website at payment to the SOCCA office at 520 N. Northwest Membership information: www.SOCCA.org/membership.php. Highway, Park Ridge, IL 60068. [email protected] Remember, payment of your dues allows you to Web Page enjoy the full privileges of SOCCA membership. You may visit the SOCCA website at: www.SOCCA.org

EDITORIAL NOTES Editorial Policy The opinions presented are those of the authors only, not of SOCCA. Drug dosages, accuracy and completeness of content are not guaranteed by SOCCA. Editor Associate Editor Editorial Board Liza Weavind, M.D. Jordan E. Brand, M.D. Francis X. Dillon, M.D. Associate Professor San Francisco VA Medical Center Elliot Fagley, M.D. Director, Critical Care Fellowship University of California Caron Hong, M.D. Department of Anesthesiology Berkeley, CA William T. O’Byrne III, M.D. Vanderbilt University Medical Center [email protected] Kevin W. Hatton, M.D. Nashville, TN James A. Osorio, M.D. [email protected] Sadeq Quraishi, M.D. Michael Woo, M.D.

A Note from the Editor to SOCCA Members: If you would like to contribute a review for a Fellowship Program at your institution in a future issue of the SOCCA Interchange, please contact Chris Dionne at [email protected]. The SOCCA Interchange is published by the Society of Critical Care Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068-2573; (847) 825-5586.

SOCCASOCCA Interchange Interchange 2 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

SOCCA 26th Annual Meeting Recap

Ronald Pauldine, M.D. Carlee A. Clark, M.D. Patricia Murphy, M.D. Clinical Professor Assistant Professor Associate Professor Department of Anesthesiology Anesthesia and Perioperative Medicine University of Toronto and Pain Medicine Medical University of South Carolina Toronto, ON, Canada University of Washington Charleston, SC Seattle, WA

The 26th SOCCA Annual Meeting and Critical commentary on the overstatement of incidence discussed the roles of colloid oncotic pressure Care Update was held on October 11, 2013 at and clinical importance of VAE, the lack of and viscosity, and postulated reasons for the the Hyatt Regency Embarcadero Center in San agreement on diagnostic criteria, that these apparent discrepancy between the published Francisco. The meeting was attended by 240 criteria are more appropriately screening literature and some guidelines for the use of members, critical care fellows and residents in criteria rather than diagnostic, and questioned human albumin. anesthesiology. A total of 39 posters, including the efficacy of particular VAE prevention The second afternoon session, “Off the abstracts of original research and challenging bundle elements. Eddy Fan, M.D., Ph.D., from Beaten Path: From Translational Concepts clinical cases, were presented. Toronto, presented an overview of the use of to Important Publications,” focused on novel The program presented updates and extracorporeal membrane oxygenation (ECMO) concepts, the translational evolution of ideas discussion in diverse areas of interest to for management of . Dr. Fan from the bench to bedside, and clinically the practicing anesthesiologist/intensivist, provided an outstanding review of the historical relevant work published in sources less including clinical management, practice evolution of ECMO in respiratory failure, familiar to anesthesiologist/intensivists. opportunities and basic and translational discussed the technological advancements John Lang, M.D., from the University of research. The first morning session, “Plus Ca that have eased implementation and reviewed Washington, presented an overview of his work Change, Plus C’est La Meme Chose: Everything recent clinical evidence in the area. The on modulating ischemic reperfusion injury Old Is New Again,” featured presentations session concluded with SOCCA President- and the potential therapeutic role of inhaled on recurring debates within the critical care Elect Aryeh Shander, M.D., FCCM, discussing nitric oxide in improving outcomes in liver community. Brian Kavanagh, M.D. delivered the longstanding debate and controversy transplantation. Sadeq Quraishi, M.D., M.H.A., an informative and entertaining discussion concerning the best fluids for resuscitating the then presented his work on the implications of the fallacy of ventilator-associated events critically ill. Dr. Shander noted wide variation of vitamin D deficiency in acute illness. (VAE) as a measurement of quality of care in practice patterns, reviewed the currently in intensive care units. The critique included available data on crystalloids and colloids, Continued on page 4

SOCCASOCCA Interchange Interchange 3 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

SOCCA 26th Annual Meeting Recap

Continued from page 3 The afternoon session began with an The Lifetime Achievement Award was interactive panel on the practice opportunities presented by Aryeh Shander, M.D. to Charles Dr. Quraishi noted that the affects of vitamin for anesthesiology-trained intensivists outside of Durbin, Jr., M.D. Dr. Durbin’s acceptance D in chronic conditions are well understood traditional academic practice. The expert panel speech, “Four Things I Thought I Knew…” but little work has been done to understand was moderated by Eugene Cheng, M.D., from offered a unique perspective on changing what role, if any, vitamin D may play in acute Kaiser Permanente in San Jose, California. His practice over time with a focus on areas that illness. Data were presented suggesting panel included members practicing in different have been ongoing sources of controversy, a possible role for vitamin D in modulating geographic areas, different practice models and including , the use of positive-end immune responses and downstream individuals with extensive past experience in expiratory pressure for management of adult implications for infection risk. The session both academic and non-academic environments. respiratory distress syndrome, steroids for concluded with a panel led by Miguel Cobas, Panelists included Christopher Barth, M.D., the management of , and organizational M.D., from the University of Miami, presenting Jordan Brand, M.D., and Steve Deem, M.D. aspects of critical care delivery systems. brief reviews of more obscure publications Research was the focus of the following The critical care update concluded with a of interest. The panel consisted of Daniel sessions, including a presentation by Erik session on controversies in neurological care Emmert, M.D., Ph.D., from Washington Kistler, M.D., Ph.D., and moderated poster in the . Andrea Gabrielli, University in St. Louis, discussing novel discussions. Dr. Kistler, a past recipient of the M.D., from the University of Florida, presented applications of ECMO, Daryl J. Kor, M.D., SOCCA/Foundation for Anesthesia Education an overview and discussion of controversies from Mayo Clinic, reviewing transfusion and coagulation and Mark Nunnally, M.D., FCCM, discussing selected topics in infectious disease. The morning concluded with the We will be meeting again for the introduction of incoming American Society of Anesthesiologists (ASA) President Jane C.K. 27TH SOCCA Annual Meeting and Critical Care Update Fitch, M.D. by SOCCA President Brenda Fahy, M.D., FCCM. Dr. Fitch delivered the annual in Montréal, Canada, on Friday, May 16, 2014. ASA update with an outline of ASA programs, goals and challenges for the coming year. The lunch break featured another successful year of the popular SOCCA and Research/Hospira Physician Scientist in care for patients following cardiac arrest. mentorship program led by Dr. Mark Nunnally. Award, presented an update on his area of Dr. Gabrielli stressed that the pathophysiology The program pairs residents with an interest research with a presentation titled “The Role following return of spontaneous circulation in critical care fellowship training with active of Digestive Enzymes in Circulatory .” Dr. in the patient following cardiac arrest is a SOCCA member mentor volunteers for advice, Kistler’s work focuses on the role of pancreatic syndrome affecting multiple organs. Potential collegiality and networking. Lunch concluded enzymes in animal models of circulatory shock areas of active treatment in selected patients with the presentation of the Young Investigator and the intriguing possibility that inactivation include therapeutic hypothermia, percutaneous Award by Patricia Murphy, M.D., to Ryan M.J. of these enzymes in the intestinal lumen may coronary intervention, and goal-directed Ivie, M.D., from Columbia University. Dr. Ivie provide therapeutic benefit. A lively moderated therapy. Current data, recommendations and presented his abstract, “The Generalizability poster session followed. The SOCCA Annual ongoing controversies in these areas, as well of Randomized Controlled Trials in Critical Meeting Planning Committee is extremely as evolving techniques and challenges for Care Medicine.” The information presented grateful to the overwhelming number of SOCCA prognosticating neurologic outcome, were stressed the point that research methodology members who volunteered to review abstracts reviewed. The final presentation of the day often limits inclusion in clinical trials, including and serve as poster moderators. It is the was a comprehensive review of the use of highly influential trials that inform much of support and involvement of our membership multimodality monitoring in the neurological contemporary practice, to patients that may that maintains the enthusiasm, volume and differ from those we actually treat. exceptional quality of the work presented. Continued on page 5

SOCCASOCCA Interchange Interchange 4 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

SOCCA 26th Annual Meeting Recap

Continued from page 4 intensive care unit by Lori Shutter, M.D., from the techniques for measuring regional cerebral blood Meeting. IARS typically meets in the spring of University of Pittsburgh. Dr. Shutter discussed flow and assessing cerebral autoregulation. each year so our next meeting will be coming up the technology, clinical applications and The day wrapped up with the SOCCA very soon. We will be meeting again for the 27th limitations of an array of devices and techniques, business meeting and a special session for SOCCA Annual Meeting and Critical Care Update including continuous electroencephalography, residents and fellows followed by a wine and in Montréal, Canada, on Friday, May 16, 2014. electrocorticography, jugular venous saturation, cheese reception. Future SOCCA meetings will Please save the date. We hope to see you there near infrared spectroscopy, brain tissue be held in conjunction with the International for another exciting and informative program. oxygenation, cerebral microdialysis and new Anesthesia Research Society’s (IARS’) Annual

27th SOCCA Annual Meeting and Critical Care Update

Friday, May 16, 2014 Fairmont The Queen Elizabeth Hotel Montréal, Canada

SOCCASOCCA Interchange Interchange 5 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

PRO: Utilization of Invasive Arterial Blood Pressure Monitoring in the Critically Ill blood pressure cuff. This method is easy, fast, Riva-Rocchi/Korotkoff technique.8 However, requires minimal training, and poses very few this study compared two non-invasive methods risks to the patient. But can this be used in in healthy patients. The validity and applicability the ICU, where inaccurate measurements can in critically ill patients of such non-invasive determine the difference between medically monitoring is unknown. Furthermore, Stover unnecessary treatments, transfusions and et al. demonstrated that Nexfin monitoring even death? A study by Bur et al. compared should not be substituted for direct arterial oscillometric blood pressure readings to blood pressure measurement, as the difference invasive arterial line readings in ICU patients in MAP between the two methods was 2± and found the mean arterial pressure was 8 mmHg.5 In a critically ill patient, this could significantly different between both readings.3 mean the difference between aggressive In general, the non-invasive blood pressure treatment versus close monitoring. readings significantly underestimated intra- While the use of a non-invasive method for arterial blood pressure measurements. blood pressure monitoring in the ICU may seem Furthermore, as the U.S. proportion of appealing, particularly in those patients who morbidly obese people steadily increases, with arterial cannulation is difficult, the applicability as many as 14 cases per 1,000 ICU admissions in the ICU has not been validated. Further Jessica Hobbs, M.D. each year being morbidly obese, there are studies must be done, as we continue to CA-3 Resident, Chief Resident concerns about accuracy of non-invasive cuff utilize the standard of care for blood pressure University of Maryland School of Medicine blood pressure measurements due to incorrect monitoring in the critically ill: direct arterial cuff sizing and lack of standardization. Araghi catheterization. et al. demonstrated that oscillometric blood Cardiovascular monitoring is essential to pressure cuffs significantly underestimated References: the care of the critically ill, particularly with blood pressure readings in all patients, 1. Ward M, Langton J. Blood pressure measurement. assessing severity of illness and assisting including patients with a BMI>30.4 Lastly, Contin Educ Anaesth Crit Care Pain (2007), 7(4):122-126. 2. Van Bergen FH, Weatherhead DS, Rrekiar AE, et al. Com- in decision-making. Since the 1700s, the there have been very few studies done to parison of indirect and direct methods of measuring arte- standard for arterial pressure monitoring determine the accuracy of blood pressure rial blood pressure. Circulation 1954, 10:481-490. in the ICU is direct arterial catheterization cuff measurements in the setting of patients 3. Bur A, Herkner H, Vleck M, et al. Factors influencing the accuracy of oscillometric blood pressure measurement in 1,2 measurement, often through the radial . on inotropic support. Until further studies are critically ill patients. Crit Care Med 2003, 31(3): 793-799. Despite being the current standard of care, done in this setting, the non-invasive cuff blood 4. Araghi A, Bander JJ, Guzman J. Arterial blood pressure direct cannulation of the artery can be difficult pressure measurements may be of questionable monitoring in overweight critically ill patients: invasive or noninvasive? Crit Care 2006, 10:R64. and is associated with risks, including osler reliability in the critically ill patient. 5. Stover JF, Stocker R, Lenherr R, et al. Noninvasive cardiac node formation, partial or complete occlusion, Another method on the forefront of non- output and blood pressure monitoring cannot replace an pseudoaneurysm formation, thrombosis invasive monitoring is the non-invasive invasive monitoring system in critically ill patients. BMC Anes 2009, 9: 6-11. 3 at the site of catheterization, and sepsis. arterial blood pressure and cardiac output 6. Bogert LW, Harms MP, Pott F, et al. Reconstruction of bra- Secondary to these risks, non-invasive arterial monitor devices. One of the most recent chial pressure from finger arterial pressure during ortho- pressure monitors have gained popularity of these is the Nexfin HD (BMEYE B.V., stasis. J Hypertens 2004, 22(10): 873-880. 7. Whinnett ZI, Davies JE, Nott G, et al. Efficiency, reproduc- in an attempt to accurately monitor arterial Amsterdam, Netherlands), which is based on ibility and agreement of five different hemodynamic mea- pressure. Experience has demonstrated that the development of the pulsatile unloading sure for optimization of cardiac resynchronization therapy. these devices are reliable in healthy volunteers, of the finger arterial walls using an inflatable Int J Cardiol 2008, 129(2):216-226. 8. Schattenkerk DW, Van Leishout JJ, Meiracker AH, et al. 5 but can this technology be used in critically ill finger cuff. It has been shown to be accurate Nexfin noninvasive continuous blood pressure validated patients in the ICU? in healthy volunteers.6,7 Schatternkerk et al. against the Riva-Rocci/Korotkoff. Am J Hypertens 2009, One method of non-invasive blood pressure showed a good correlation between Nexfin 22(4):378-383. monitoring being used is the oscillometic and blood pressure measurement by the

SOCCASOCCA Interchange Interchange 6 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

CON: Utilization of Invasive Arterial Blood Pressure Monitoring in the Critically Ill such as damping of the arterial wave or changes Arterial tonometers utilize a specific in transducer height. There are also patients piezoresistive transducer and a micro- with particular injury patterns or predisposing processor-based electronic system to continu- medical conditions, making arterial cannulation ously monitor blood pressure waveforms. difficult or impossible, including some critically Martina et al. showed safe and reliable blood ill patients, trauma, peripheral vascular disease pressure monitoring with arterial tonometers and the pediatric populations.3 Additionally, in anesthetized patients compared with improvements in non-invasive blood pressure concurrent invasive arterial blood monitoring monitoring technology, such as the Nexfin in age groups ranging from 8-82 years old.4 (BMEYE, Amsterdam, The Netherlands), contour monitors, such as the Nexfin, T-Line TL-200 (Tensys Medical), Intellivue have also been shown to be effective. It utilizes MP50 (Philips), may allow wider application an inflatable cuff positioned on a finger and of these systems in the perioperative and measures continuous BP (systolic, diastolic, intensive care units (ICUs). mean) and heart rate and calculates continuous

Lindy Watanaskul, M.D. CA-2 Anesthesiology Resident Technological innovations, such as arterial tonometers University of Maryland Medical School and pulse contour monitors, are becoming increasingly utilized and have shown that they are both accurate and efficacious.

Many of us have debated about the need for invasive arterial monitoring in patients. Despite having clear indications for invasive blood pressure monitoring insertion, there Current modes of blood pressure cardiac output (CCO), stroke volume (SV) are a significant number of patients who monitoring most useful in the critical care and systemic vascular resistance (SVR).5 The receive unnecessary invasive procedures that and perioperative setting include intermittent ease of use of this technological advancement can lead to more harm than good. Although upper-arm sphygmomanometers, electronic allows many health providers to quickly obtain most peripheral cannulations are performed oscillometric monitors, arterial tonometry and valuable hemodynamic information. The safely, there are still risks and complications. pulse contour monitors. Electronic oscillometric utility in the critical care setting is promising. Scheer et al. discussed the risks of peripheral monitors are accurate, inexpensive, require Martina et al. evaluated 50 patients undergoing arterial cannulation for invasive blood pressure little experience and are the main method cardiothoracic and compared non- monitoring, including temporary occlusion, of blood pressure monitoring. However, this invasive arterial blood pressure monitoring pseudoaneurysms, sepsis/infection, ischemia, method has limitations, including inaccuracy in with invasive arterial blood pressure monitoring abscess and hematoma formation.1 In the obese patients, questionable validity in critically during a 30-minute period. Results showed perioperative period, arterial cannulation ill patients with hemodynamic instability, and that values were comparable to each other with can also add time in the operating room inability to visualize waveforms and monitor correlation coefficients for systolic, diastolic and (O.R.), dependent on provider experience and beat-to-beat blood pressure variations. mean pressures 0.96 (0.91-0.98), 0.93 (0.87- expertise. The cost of O.R. time per minute can Technological innovations, such as arterial 0.96), 0.96 (0.90-0.97), respectively.6 Fischer range anywhere from $22 to $133 per minute, tonometers and pulse contour monitors, are et al. studies a similar number of patients and added time for invasive arterial cannulation becoming increasingly utilized and have shown postoperatively following cardiac surgery, can prove costly.2 Invasive monitoring can also that they are both accurate and efficacious. lead to false readings from errors and artifacts Continued on page 15

SOCCASOCCA Interchange Interchange 7 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

Barrier Precaution Recommendations for Arterial Line Placement

Brian Wessman, M.D. Jessica Smith, M.D. Alex Kim, M.D. Co-Director, Critical Care Fellowship Assistant Professor Assistant Professor Assistant Professor of Anesthesiology and Washington University University of New Mexico Emergency Medicine School of Medicine Health Sciences Center Washington University School of Medicine Saint Louis, MO Albuquerque, NM Saint Louis, MO

Patient Case Vignette: Secondary to multiple professional opinions 3) Rijnders B, et al. Use of full sterile barrier A 71-year-old male with a past medical regarding appropriate barrier techniques for precautions during insertion of arterial history for HTN, DM and PVDz is admitted to arterial line insertion, we were asked to provide : A randomized trial. Clinical the intensive care unit in requiring a formal recommendation regarding this Infectious Disease. 2003; 36:743-48. vasopressors and . topic. Our goal was to review the most recent He is POD #8 from a lower extremity literature, summarize and provide a formal 4) Esteve F, et al. Bacteremia related with revascularization procedure and his presumed recommendation. arterial in critically ill patients. source is pneumonia. As you are actively Journal of Infection. 2011; 63:139-43. Literature Reviewed: titrating vasopressors with his resuscitation, 1) Pronovost P, et al. An intervention to a decision is made to place invasive arterial decrease catheter-related bloodstream 5) Hammarskjold F, et al. Low incidence of access for monitoring. After failing to obtain infectious in the ICU. New England Journal arterial catheter infections in a Swedish radial arterial access, you decide to access an of Medicine. 2006; 355:2725-32. intensive care unit: risk factors for axillary arterial site under ultrasound guidance. colonization and infection. Journal of As you prepare for the procedure, the nurse 2) Lucet J, et al. Infectious risk associated with Hospital Infection. 2010; 76:130-134. asks if you will need a full barrier drape and full arterial catheters compared with central body gown/cap for sterility, similar to best care venous catheters. Critical Care Medicine. Continued on page 9 practice policy for central venous cannulation. 2010; 38:1030-35.

SOCCASOCCA Interchange Interchange 8 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

Barrier Precaution Recommendations for Arterial Line Placement

Continued from page 8

Literature Summarized: after the fifth day. This group calls into arterial lines as compared to 4.98 episodes 1) This NEJM article, often referred to as the question the practice of scheduled “wire- per 1,000 catheter days for CVP. All their Keystone Initiative, looks at the institution over” changes of central venous catheters arterial lines were placed with sterile gloves, of CDC recommendations for the reduction and arterial lines secondary to these findings. gown, mask, cap and sterile drapes around of catheter-related bloodstream infections Of note, the protocol used in this study was the insertion site. The results obtained showed in more than 100 Michigan ICUs. The full barrier drapes for insertion of arterial that what was associated with increased risk five evidence-based procedures instituted catheters at the radial site. for a BSI were length of ICU stay and days were: hand-washing, using full barrier of insertion. They also showed only a trend precautions during the insertion of central 3) This was a randomized trial (from Belgium) to toward higher infection risk in femoral sites venous catheters, cleaning the skin with investigate whether the use of maximal barrier compared to radial, although when there was chlorohexadine, avoiding the femoral site precautions, similar to those used in placing a an infection in the femoral site, it was often if possible, and removing unnecessary , decreased the rate associated with gram negative bacteria. catheters. They report the ability to institute on infection when placing arterial lines (sites: this protocol and a sustained reduction (up to radial and dorsal pedis). The control group 5) This was a prospective observational study 66 percent) of bloodstream infections from was the use of hand-washing, sterile gloves, (in Sweden) to determine incidence and central venous catheters throughout the and skin disinfection with chlorohexidine and risk factors for arterial catheter colonization 18-month study period. alcohol. They found no difference between and arterial colonization catheter-related infections in a single ICU. In this study, 600 arterial catheters were placed using sterile gloves and chlorhexidine, and they found no Central venous catheters and arterial lines appear to share cases of arterial catheter-related blood stream infections. There were 20 (3.3 percent) cases similar risk factors for bacterial colonization, which is different of arterial catheters with a positive tip culture, than what was previously believed. These risk factors appear to but again, none of these were deemed to be associated with length of time of line insertion, non-sterile cause a blood stream infection (defined as SIRS criteria and positive tip culture). This access/manipulation of the line, and number of ICU days. group advocates that full protective barrier (mask, cap and gown) would not decrease the incidence of arterial-related blood stream infections. Risk factors for arterial catheter 2) The objective of this observational study the incidences of colonization between the tip colonization appears to be a coexisting (done in France) was to compare the daily risk two groups. There was also no difference infected central venous catheter. factors for invasive catheter colonization and in infection rates between the two groups. risk factors for catheter-related bloodstream Of note, the authors do comment on the Summary Discussion: infections from both arterial lines and use of cumbersome guide-wires (Seldinger Published data exist to support the need for central venous catheters. The group reports technique) and their risk of increasing full barrier precautions for the insertion of central that the risk of line colonization did not infection. venous catheters. This same data do not exist for differ significantly between central venous arterial line insertion. Central venous catheters catheters and arterial lines. They also report 4) This study was a retrospective, non- and arterial lines appear to share similar risk an interesting finding of the risk of colonization randomized trial (in Spain) to analyze the factors for bacterial colonization, which is increasing in a linear fashion over time for incidence of arterial catheter-related BSI in different than what was previously believed. arterial lines; while the risk of colonization of radial and femoral sites. What they found was central venous catheters appears to plateau 3.53 episodes per 1,000 catheter days for Continued on page 10

SOCCASOCCA Interchange Interchange 9 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

Barrier Precaution Recommendations for Arterial Line Placement Continued from page 9

These risk factors appear to be associated Recommendations: Returning to Our Patient Case Vignette: with length of time of line insertion, non-sterile 1) {data} Peripheral arterial line insertion sites Since you have transitioned from a “peripheral access/manipulation of the line, and number of (radial and dorsal pedis): isolate the extremity, arterial site” to a “central arterial site,” the ICU days. There may be correlation between wide local barrier drapes (sterile towels) with axillary artery in this case, you decide to take coexisting contaminated vascular lines and sterile techniques (gloves, chlorhexidine); full a few extra minutes to provide maximal sterility greater infectious rates. Arterial lines placed at barrier set-up is not required. for your patient in septic shock. You observe full- peripheral sites (radial and dorsal pedis) can be 2) {extrapolated} Prolonged attempts using a body sterility techniques by using a gown, cap placed using local barriers and sterile technique. non-protected (30 min)/ and bed drape. The results obtained indicated Concern does exist in the literature of possible multiple providers (>3) at a peripheral arterial the increased risk of BSI was associated with contamination complications from arterial lines line insertion site: strongly consider changing ICU LOS and number of days since insertion. The placed using the Seldinger technique and long to a full barrier set-up (caps, gown and bed procedure is completed without complication. guide-wires. Therefore, these same techniques drape) or re-draping the insertion site. (0.87-0.96), 0.96 (0.90-0.97), respectively.6 may not work for centrally placed arterial line 3) {extrapolated} Femoral and axillary arterial Fischer et al. studies a similar number of patients sites (femoral, axillary). Due to line colonization line insertion sites may benefit from full postoperatively following cardiac surgery. risks, accessing/manipulation of lines should be barrier set-up or recognition of guide-wire recognized as increasing bloodstream infectious awareness. risk, and “clean techniques” should always be 4) {data} Physicians/nurses accessing all observed. Secondary to these risks, rewiring invasive lines should be instructed to ALWAYS of all lines (central venous and arterial) greater use “clean techniques” (gloves, alcohol swab than 48 hours old may increase the risk of a to port hub, etc.) secondary to known line bloodstream infection. colonization risks. 5) {extrapolated} Rewiring arterial lines that are greater than 48 hours old may increase the risk of a bloodstream infection (due to line colonization) and this should be weighed as the procedure is discussed

SOCCASOCCA Interchange Interchange 10 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

Emergency Medicine ACCM Training

clinical exposure but requires specific surgical exposure as an advanced preliminary resident critical care time (both during the first year and to surgical rotations (as determined by the by completion of the training cycle). surgery residency director and the SCC Emergency medicine trainees have been fellowship program director). The second year pursuing critical care medicine fellowships is completion of the standard SCC training through various venues since the late 1970s, curriculum. but no formal pathway to U.S. certification The ABA/ABEM cosponsored pathway is existed.2 Many EM/CCM trainees resorted to unique in its approach to be all-inclusive and obtaining formal certification from the European to create the potential flexible framework Society of . Currently, for a well-rounded multidisciplinary clinical- there are more than 200 EM/CCM fellowship based training curriculum for the EM/CCM trained physicians practicing in various models fellow.1 The EM applicant has the prerequisite in the U.S. of needing to complete four months (16

Brian Wessman, M.D. Co-Director, Critical Care Fellowship Graduates of EM residency programs are unique Assistant Professor of Anesthesiology and in their training and background, making them Emergency Medicine Washington University School of Medicine, ideal candidates for critical care medicine training. Saint Louis, MO

Starting with academic year 2014, a co- sponsored pathway to critical care medicine The American Board of weeks) of ICU rotations during residency as certification from the American Board of (ABIM) and ABEM announced a co-sponsored well as successfully completing an ACGME Anesthesiology (ABA) and the American Board pathway to formal U.S. CCM certification with EM residency. The pathway requires that of Emergency Medicine (ABEM) will take effect the first exam being offered in 2011.3 Twenty- all EM/CCM fellows complete 24 months of for potential fellowship trainees with a primary five diplomates took this initial certifying training in an approved ACCM curriculum. residency in emergency medicine.1 Earlier this exam with all of them successfully obtaining This is required of EM applicants, regardless year, the American Board of Medical Specialties certification.4 Specifics of the ABIM/ABEM of whether they have completed a three-year formally approved this new training pathway CCM pathway include a 24-month curriculum (36-month) or four-year (48-month) residency as well as a limited grandfathering pathway and a prerequisite of completing six months program. The two-year curriculum requires (expiring 2018). The new pathway requires that of internal medicine exposure (three months that both years of training be completed at the emergency medicine/critical care medicine in a MICU setting) prior to/or in conjunction the same ACCM site. During the first six- (EM/CCM) candidate complete two years of with the start of the fellowship training.3 The months of fellowship training, the EM/CCM critical care fellowship training at an ACGME- American Board of Surgery (ABS) subsequently fellow should have exposure to at least three approved anesthesiology critical care medicine announced its own unilateral (not cosponsored surgical-based rotations, and by completion of (ACCM) program. These ACCM programs must by ABEM) EM surgical critical care (SCC) the 24-month cycle, the EM/CCM fellow should apply with the ABA and be approved for a two- training pathway.5 Specifics of the ABS have completed a total of 12 months of surgical year EM/CCM training track. The fellowship pathway include completion of 24 months of exposure. However, latitude does exist in how curriculum allows latitude for multidisciplinary training, with the first year requiring primary Continued on page 12

SOCCASOCCA Interchange Interchange 11 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

Emergency Medicine ACCM Training Continued from page 11 to define “surgical exposure.” For example, this (hypoxia, COPD, asthma, PNA, etc.), sepsis, growth of our specialty. Due to its inclusive requirement could be met in a “mixed” medical/ toxicology, blunt/penetrating trauma patient, nature, EM/CCM trainees will be attracted surgical ICU or rotations such as “nephrology” GI hemorrhage, wound care, burn injuries, to ACCM programs as long as we continue to and “infectious disease” as long as sufficient metabolic derangements, etc.6 Procedural grow the number of potential slots in approved exposure to surgical patients was gained. The acumen with emergent airway stabilization, training programs. This new influx of trainees requirements also encourage multidisciplinary vascular/arterial access, thoracostomy, para/ will continue to strengthen our ranks and critical care exposure to rotations such as thora/cardio-centesis, and point-of-care improve our visibility on the national scene. pulmonary medicine, bronchoscopy, , ultrasound imaging, among other procedures, Please feel free to contact the ACCM etc., as well as anesthesiology rotations (pre-op is expected of the EM graduate.6 The annual program at Washington University or perioperative rotations). This pathway is a interest by EM residency graduates in the in Saint Louis School of Medicine, clinical-based curriculum and requirements do specialty of critical care medicine continues to [email protected]. Future publi- stress that no more than two elective rotations rise creating a nice addition to the existing pool of cations will look at specifics regarding our (two months) can be spent pursuing research. anesthesiology residency graduates interested multidisciplinary curriculum and training ACCM programs must apply for formal EM/ in ACCM fellowship training. With a deeper pool program history. CCM two-year curriculum approval through the of applicants, the specialty of anesthesiology ABA.1 This application is a simple document that CCM can continue to expand by cultivating and References: requires information regarding existing ACGME developing future intensivist leaders. 1. http://www.theaba.org/Home/notices . American Board of training programs (CCM, SCC, anesthesiology), The EM/CCM training tract is a two-year Anesthesiology webpage. 2013. 2. Mayglothling JA, et al. Current practice, demographics, and proposed EM/CCM curriculum and how the curriculum. The first year of EM/CCM training, trends of critical care trained emergency physicians in the surgical exposure requirements are met, and similar to any anesthesia ACCM fellow, does Untied States. Academic Emergency Medicine. Mar 2010. select signatures from institutional leadership count against a program’s approved complement 17 (3): 325-9. 3. http://www.abim.org/news/critical-care-medicine.aspx . (including the anesthesiology chair). Currently, of fellows; however, the second year of training American Board of Internal Medicine webage, 2013. there are only two national ACCM programs that does not “count against” your total tally. This 4. Wessman, B. Emergency Medicine Section News. SCCM have received formal ABA EM/CCM curriculum will provide ACCM training programs with Critical Connections. April 2013. 5. http://www.absurgery.org/default.jsp?certsccce_abem. The approval: Washington University School of the ability to expand the bandwidth of patient American Board of Surgery webpage. 2013. Medicine in St. Louis, and Case Western Reserve coverage models. Specifically, “senior” level 6. ACGME Program Requirements for Graduate Medical University. The hope would be to have continued fellows can help with patient care transitions at Education in Emergency Medicine. ACGME approved September 30, 2012. growth with more ACCM-established programs the start of the academic cycle and orient a new seeking EM/CCM formal training approval. class of ACCM trainees. One obvious downside Graduates of EM residency programs are and growth limitation of this two-year training unique in their training and background, making model is procuring funding for the second year. them ideal candidates for critical care medicine Potential funding could be requested of the training. During residency, they are required to hospital as critical care needs continue to expand have exposure to the undifferentiated critical and further revenue is generated from patient care patient and part of their specialty training care. Alternatively, supplemental funding could is stabilization of this patient population prior to be provided by departmental educational funds. arrival in the ICU setting.6 They become adept The ABA/ABEM co-sponsored agreement at multitasking and providing critical care for is a major development both for emergency emergent cardiac failure (STEMI, heart failure, medicine but also for anesthesiology CCM. The arrythmias, cardiopulmonary failure, etc.), acute certification pathway was well structured to neurologic events (stroke, status epilepticus, allow growth of multidisciplinary training intracranial hemorrhage, etc.), respiratory failure curriculums as well as to foster continued

SOCCASOCCA Interchange Interchange 12 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

Fellowship Program Directors Breakfast Summary

The majority of ACCM program directors The majority of programs have agreed to (PDs) were able to meet this October in San participate and we are all excited to incorporate Francisco to discuss pertinent issues of this paradigm. I think we all believe it is in concern to all of us. We began our meeting the best interest for programs and, more promptly at 7 a.m. with an update by Dr. Rob importantly, for applicants. Sladen on the status and direction of AASPD. Our next meeting was scheduled for the As a group, we have begun collaborating with AASPD on Friday, November 1. At that time, we the ACTA members on many issues and have will meet as a PD group and I have set aside decided, for the first time, to meet as a group time to meet with the ACTA PDs as a larger at this year’s AASPD in Philadelphia. Both Dr. group to discuss issues of common interest Doug Coursin and Dr. Neal Cohen were able (i.e., how to expand our dual ACCM/ACTA to provide their valuable insights into issues fellowship programs). surrounding ABA and RRC. In particular, while Finally, it has been an absolute honor to the ABA recently announced a novel pathway serve as the inagural chair of the PD committee for EM residents to enter ACCM fellowships, for the past several years. I feel that we have many of the details are still vague and it will accomplished a great deal as a group and the be up to the individual programs to create future of our specialty looks genuinely bright. Benjamin A. Kohl, M.D., FCCM innovative paradigms. Several programs have My successor will be Dr. Miko Enomoto, from Chief, Division of Critical Care already applied and received approval for a the Oregon Health & Science University, who I Program Director, combined training program, and we were able know will do an outstanding job of leading our Adult Critical Care Medicine Fellowship to hear the plans that they had laid out. group. I look forward to seeing everyone soon, Medical Director, ACCM fellowship programs will be engaging either at AASPD or SCCM. Penn ELert Telemedicine Program in our first match this year (for fellows starting Department of Anesthesiology and Critical Care July 2015). The match service we decided Perelman School of Medicine, to use was SF Match, similar to our CTA University of Pennsylvania colleagues. Important dates are the following:

• Registration opens November 1, 2013

• Rank list submission deadline May 22, 2014

• Match results available May 29, 2014

• Training begins July, 2015

SOCCASOCCA Interchange Interchange 13 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

Fellowship Review: The University of California, San Francisco (UCSF)

The fellowship year includes seven months of ICU at Moffitt/Long Hospital, a tertiary referral center. The patient population includes major surgical cases such as: heart, lung, liver and kidney transplantation, extra-corporeal , major orthopedic, general, and vascular surgery as well as medical cases, including hematologic malignancies, ARDS, renal failure and neurologic disorders. An additional two months are spent at San Francisco General Hospital, a level 1 trauma center. These rotations include exposure to the trauma ICU and an additional medical intensive care unit (MICU). The fellowship program offers a diverse array of choices for the remaining three months of elective time. Popular electives include Zeb McMillan, M.D. nephrology, infectious disease, cardiac echo/ Critical Care Fellow ultrasound, palliative care, research, nutrition, University of San Francisco respiratory care or radiology. Special electives can be developed in nearly any area to suit the individual clinical or research interests of The Critical Care Fellowship Program at the fellow. The Critical Care Group at UCSF the University of California, San Francisco is has multiple NIH-funded grants, in addition an ACGME-accredited one-year program that to a number of innovative foundation-funded San Francisco itself hosts hundreds (if not provides a wide breadth of experience covering programs. thousands) of interesting attractions. From all aspects of critical care medicine. Fellows Fellows are responsible for supervising and tourist sites such as Chinatown and Alcatraz, in the program rotate through two 16-bed teaching residents and giving didactic seminars to amazing hole-in-the-wall eateries and local combined medical-surgical ICUs, the 24-bed during morning lectures, grand rounds, and breweries, San Francisco has something for /neurosurgical ICU, and the 16-bed morbidity and mortality reviews. They also everyone. Within a short drive, you can cruise cardiology/cardiothoracic ICU. assist with patient triage and patient transfer. along the beautiful coastal highway to go The multidisciplinary program includes The didactic curriculum includes daily lectures surfing, go to Napa for a wine tour, visit Lake fellows from anesthesiology, internal medicine, for the first two weeks of the fellowship and Tahoe to go skiing or camping, or cross over neurology, surgery and emergency medicine, then weekly conferences with the faculty the Golden Gate Bridge to visit and hike through all working interchangeably throughout the on various ICU topics throughout the year. Muir Woods. ICUs. The exposure to nearly every type of Fellows also attend a two-day focused critical Aside from enjoying the art and culture patient and disease process is enhanced by care ultrasound course followed by weekly of this beautiful city, graduating fellows are the experiences of the other specialty fellows ultrasound journal clubs, where patient images prepared well for board certification and within the program. The attending physician are presented and reviewed. Twice a year there critical care practice in both academic coverage also derives from multiple specialties, are patient simulations in a state-of-the-art and private settings. For more information which helps to strengthen the teaching program simulation lab. Mock scenarios are presented regarding the program, please contact our and to provide fellows with exposure to broad- and fellows can obtain immediate direct Fellowship Program Director, Dr. Linda Liu based approaches to the management of feedback on their performance. [email protected],or our Program critically ill patients. Coordinator at fellowships@anesthesia. ucsf.edu.

SOCCASOCCA Interchange Interchange 14 Volume 2524 Number 15 S O C I E T Y O F C R I T I C A L C A R E A N E S T H E S I O L O G I S T S

CON: Utilization of Invasive Arterial Blood Pressure Monitoring in the Critically Ill

Continued from page 7 References: 1. Scheer BV, Perel A, Pfeiffer UJ Clinical review: Complica- demonstrating safe, reliable and convenient tions and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive monitoring utilizing pulse contour monitors with care medicine. Crit Care. 2002; 6(3):199-204. a significant statistical relationship for systolic, 2. Macario A. What does one minute of operating room time diastolic and mean pressures.7 cost? Journal of Clinical Anesthesia. 2010; 22:233-236. 3. Cousins TR, O’Donnell JM. Arterial cannulation: A critical Noninvasive arterial blood pressure review. AANA Journal. 2004; 72. monitoring, such as pulse contour monitors, 4. Kemmotsu O, Ueda M, Otsuka H, Yamamura T, Winter would be useful in critically ill patients where DC, Eckerle JS. Arterial tonometry for noninvasive, con- tinuous blood pressure monitoring during anesthesia. arterial catheterization is difficult or prolonged Anesthesiology. 1991; 75:333-340. catheters are no longer acceptable options and 5. Chen, Guo, et al. Comparison of noninvasive cardiac out- diligent hemodynamic monitoring is essential. put measurements using the Nexfin Monitoring Device and the esophageal doppler. Journal of Clinical They have demonstrated efficacy in the Anesthesia. 2012; 24:275-83. perioperative and ICU setting and should be 6. Martina JR, Westerhof BE, van Goudoever J, de Beaumont considered effective, safe and reliable. EM, Truijen J, Kim YS, Immink RV, Jöbsis DA, Hollmann MW, Lahpor JR, de Mol BA, van Lieshout JJ. Noninvasive continuous arterial blood pressure monitoring with Nexfin®. Anesthesiology. 2012; 116:1092-103. 7. Lemson J, Hofhuizen CM, Schraa O, Settels JJ, Scheffer GJ, van der Hoeven JG. The reliability of continuous noninvasive finger blood pressure measurement in critically ill children. Anesth Analg. 2009; (108):814-21.

New Date & Location SAVE THE DATE th Annual Meeting and 27 Critical Care Update May 16, 2014 | Montréal, Canada

SOCCASOCCA Interchange Interchange 15 Volume 2524 Number 15 ASA is here to help you fulfill MOCA® requirements. Designed to help physicians demonstrate their commitment to quality clinical outcomes and patient safety, ASA’s MOCA® products and activities are a simple click away – education.asahq.org/moca.

SAM-CC is a new self-study CME program that covers established knowledge in the subspecialty field of critical care medicine.

SAM-CC helps satisfy the Part 2 Self-Assessment CME component of MOCA® and features: • 100 questions and answers • detailed discussions explaining the rationale for each answer and references for further study • online access at your convenience • up to 30 AMA PRA Category 1 Credits™ • plus much more…

This program was developed through a partnership between:

Society of Critical Care Anesthesiologists

To learn more and order your module today, visit education.asahq.org/samcc or for questions, call (847) 825-5586

Accreditation and Credit Designation The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The American Society of Anesthesiologists designates this enduring material for a maximum of 30 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

education.asahq.org/samcc SOCCA Interchange 16 Volume 25 Number 1