Citations

OBJECTIVES: The overall goal of this work is to discuss the various topics associated with critical care advanced practice provider (APP) postgraduate training programs and provide resources for new, developing and existing programs. DESIGN: Three rounds of voting until consensus achieved. SETTING: Electronic surveys, followed by virtual meeting. SUBJECTS: Critical care APPs, physicians, a pharmacist, and a nurse were also included to ensure multidisciplinary representation. All subjects resided and practiced in the United States with a history of education scholarship or post-graduate training leadership. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The workgroup included 14 APPs (ten nurse practitioners and four physician associates), three physicians, one pharmacist, and one registered nurse from 14 institutions across the United States. The workgroup identified six areas of concentration: administration, audience, program structure, curriculum, procedural competence, and accreditation. A survey was generated and employed in three rounds. The first two rounds of voting were completed anonymously, the third round was completed as a live meeting until consensus recommendations, defined as 75% agreement or more, were achieved. CONCLUSIONS: Expert consensus was used to generate consensus recommendations for critical care postgraduate training programs based upon 3 rounds of voting.

BACKGROUND: Percutaneous tracheostomy (PT) is generally considered a safe procedure, but complications such as malpositioning, bleeding, and tracheal ring rupture remain concerns, particularly during initial needle insertion. This study investigates the feasibility, ease of use, and safety of a novel device and technique for bedside PT, named the Illuminated Tracheal Alignment Guide (iTAG). METHODS: An interventional pilot study evaluated the feasibility and safety of the iTAG device and method. The study was approved by our local institutional review board and a Food and Drug Administration waiver was granted for use of our device. Patients in a neurocritical care unit requiring tracheostomy were screened and consented for inclusion. Exclusion criteria included significant vascular overlap and specific ventilator settings. The iTAG method involves a laser light source and a needle guide with a hard stop, used in conjunction with standard PT equipment. Data on demographics, procedure details, and early complications were collected and compared with historical control data from patients who underwent standard tracheostomy (ST). RESULTS: From January 2023 to July 2024, 30 patients underwent PT using the iTAG device. The mean time from intubation to tracheostomy was 15.53 days, with a mean ICU length of stay of 31.14 days. The iTAG group experienced significantly fewer early complications compared with the historical ST control group, including reduced hemorrhage, and there were no instances of tracheal ring fracture, posterior wall injury, or pneumothorax. The iTAG method allowed for safe PT in all patients. CONCLUSIONS: The iTAG device enhances the safety and efficacy of PT by providing precise visualization and limiting needle penetration, reducing early complications. Its use expands patient candidacy for PT and offers a valuable tool for training less-experienced practitioners. Further research with larger cohorts and randomized controlled trials is needed to confirm these findings and establish the iTAG method as a standard of care for PT.

Background Intraventricular hemorrhage is a calamitous type of stroke where bleeding into the ventricular system can be defined as: primary, if confined within the ventricles; or secondary, due to intracerebral hemorrhage extending from adjacent parenchyma. Intraventricular blood clot can lead to secondary insult and inflammatory responses that culminates in hydrocephalus as the most common cause of death. Purpose THerein, we report a patient with a high modified Graeb scale and low Glasgow coma scale. She spontaneously recanalized her fourth ventricle, decompressed her reticular activating system with remarkable spontaneous bilateral eye opening, and a consequently experienced a halfway drop in her mGS. Results This is the first reported case of a spontaneous recanalization of 4th ventricle obstruction secondary to IVH without intervention and subsequent dramatic neurological improvement. We believe that the apixaban primarily preserved the liquid state of hemorrhage and her presumed elevated ICP was sufficient to push out the liquified blood in the 4th ventricle into the upper spinal canal , recanalizing the 4th ventricle by continuously creating downward CSF pressure waves. Given the RAS location around the 4th ventricle, we hypothesize spontaneous decompression from the clot lysis triggered the RAS activation with sudden arousal manifested as spontaneous bilateral eyes opening. Hence, we refer to this as the reticular activating system reactivation after ventricular hemorrhage evacuation, or simply the “REVIVE” phenomenon. Conclusion This dramatic improvement from coma to awake state is worthy of recognition for future neurotherapeutic interventions.

Background Education opportunities for night shift nurses are limited compared with those for their day-shift counterparts. However, patients remain critically ill regardless of shift and require intensive nursing care at all hours. Overnight, this care is often provided with fewer resources. These challenges can lead to disengagement and high turnover on the night shift. Objectives To see whether initiation of an informal education series called “Coffee Talk” could improve accessibility to learning for night shift nurses and elevate perception of support from administrators and overall job satisfaction. Methods The lecture series was created to facilitate education for night shift nurses. The program features various speakers within the interdisciplinary team discussing topics chosen by the nursing staff. The talks are presented in an informal setting during overnight hours. An electronic survey tool was used to determine nurses’ opinions regarding Coffee Talk, using a retrospective pretest and posttest format. Questions centered on the type of educational offerings, relevance to practice, perceived leadership support, convenience of attendance, and overall job satisfaction. Results More than half of the nurses (59%) responded. All scores improved from before to after the intervention. The largest increases occurred in convenience of educational offerings and nurses’ perception of leaders removing barriers to learning. Overall job satisfaction increased from 83% to 93%. Conclusions The introduction of an informal educational series improved nurses’ access to education and nurses’ feelings of support from administrators and overall job satisfaction.