Intensive Care Strain Indicators: Recommendations for Critical Care Processes and Research Objectives
Rachael W. Starcher1, Craig R. Weinert1, Kiersten Henry2, Jeffery R. Dichter1*
1Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
2MedStar Montgomery Medical Center, Olney, MD, USA
Intensive care units (ICU’s) are particularly susceptible to resource and personnel strain given the complexity and unpredictability of care. This featured prominently in the early course of the SARS-CoV-2 (COVID-19) pandemic, where poor patient outcomes were clearly linked to the increasing severity of ICU strain associated with decreased ICU capacity. Despite attempts at measuring ICU strain, there exists no operational model that ICU directors can implement to monitor strain or researchers can use to examine its effects.
This article reviews ICU strain indicators including census load (census, acuity, and admissions), ICU flow characteristics (admission/discharge criteria, sufficient staffing levels, and ICU performance), and consequence mediators (ICU queuing time and high-risk discharges) with attention to common themes and measures. Census load data suggests mortality risk is greater when ICU census starts higher, has high overall acuity, and with greater numbers of admissions especially when they arrive close together. Optimal ICU flow depends on maintaining a “strain mindset” when prioritizing patients, optimal ICU professional staffing, and maintaining high level ICU performance processes. Finally, delaying ICU admissions beyond six hours, or “after hours” or rushed ICU discharges result in increased mortality risk. Incorporating these ICU strain factors into an outcomes-focused model is proposed based on a conceptual framework with future research objectives recommended.
DOI: 10.29245/2768-5365/2023/1.1138 View / Download PdfAssessment and Management of Difficult Airway Post Mandibulectomy: A Narrative Review
Swati Patel, Ashwini Reddy, Amiya Kumar Barik*, Shiv Lal Soni, Narender Kaloria
Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Mandibulectomy most commonly performed as surgical management of oropharyngeal carcinoma leads to a wide array of anatomical and physiological changes which result in an anticipated difficult airway. There may be posterosuperior displacement of hyoid bone and tongue leading to reduction of retropalatal space along with loss of structural support to the tongue predisposing it to prolapse and development of obstructive sleep apnoea. Bulky flap reconstruction, limited mouth opening, and radiotherapy limiting neck mobility further compound the difficulty in airway management. This leads to a wide spectrum of issues ranging from difficulty in face mask ventilation to laryngoscopy and intubation. It is essential to individualize each case with a preformulated strategy outlining the primary and alternative approaches. A literature search was carried out using search engines like PubMed, Embase, Medline, and Google scholar using the terms “Difficult airway”, “Post-mandibulectomy”, “Difficult laryngoscopy, and Intubation”. The available literature was thoroughly reviewed by the authors before the final drafting of this article. A multidisciplinary team approach, thorough assessment, meticulous preparation, and critical decision-making are essential for successfully managing a difficult airway post-mandibulectomy.
DOI: 10.29245/2768-5365/2023/1.1137 View / Download Pdf