1. s February 20-24, 2016 s Orange County Convention Center
s Orlando, Florida, USA
Register Today
for the 45th
Critical Care Congress
Visit www.sccm.org/Congress
for details.
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Critical Connections
Volume 14, Number 4
August/September 2015
Until recently, what it meant to survive critical illness remained largely
unknown. As a result, fundamental questions centered on whether such
survivors have good long-term outcomes, whether these outcomes are the
best possible results based on the provided care, and whether care would
change if we knew more about outcomes beyond the intensive care unit
(ICU) discharge required urgent examination.1
Over the last decade, the
science on long-term outcomes following critical illness has begun to fill
these essential knowledge gaps.
What we have learned is that many survivors of critical illness experience
post-intensive care syndrome (PICS).2,3
In 1999, Hopkins and colleagues
demonstrated the startling frequency with which acute respiratory distress
syndrome survivors experienced long-term cognitive impairment4
; since then,
the evidence has confirmed that survivors of many critical illnesses frequently
develop new or worsening impairments in neuropsychological or physical
function.5-8
The Society of Critical Care Medicine (SCCM) has been the
leader in bringing together clinicians and scientists to name and define PICS.2
“Why ICU Clinicians Need to Care about
Post-Intensive Care Syndrome” p 9
Clinical Spotlight
Why ICU Clinicians Need to Care about
Post-Intensive Care Syndrome
Clinical Spotlight
Helping Critically Ill Patients and Families
Thrive through an ABCDEF Approach
In This Issue…
Post-Intensive Care Syndrome
Learn about the role of each team
member in a post-intensive care
syndrome clinic. . . . . . . . . . . . . . . . . . 6
Explore models for a post-intensive
care syndrome clinic. . . . . . . . . . . . . . 7
See how your institution can
improve long-term outcomes for
pediatric patients. . . . . . . . . . . . . . . . . 8
Thank you for your membership in
the Society of Critical Care Medicine.
Learn more about the benefits of
membership at www.sccm.org or
call +1 847 827-6888.
Post-intensive care syndrome (PICS) is a devastating and often
life-altering condition experienced by an increasing number of
critically ill patients and their family members. As described
by a 2010 Society of Critical Care Medicine (SCCM) task
force,1
PICS is a complex syndrome that encompasses new or
worsening impairments in physical, cognitive, or mental health
status arising after critical illness and persisting beyond acute
care hospitalization. While the etiology of PICS is complex
and believed to be multifactorial, evidence generated during
the past several decades suggests that there are a number of
important, potentially modifiable risk factors that may be
reduced through early and reliable adoption of interprofessio-
nal, evidence-based intensive care unit (ICU) interventions. As
outlined in SCCM’s Clinical Practice Guidelines for the Management of
Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit,2
some of these safe and effective interventions include: maintai-
ning light levels of sedation, using nonbenzodiazepine-based
sedatives, administering valid and reliable pain, agitation, and
delirium (PAD) monitoring tools, and performing early mobiliza-
tion whenever clinically feasible.
“Helping Critically Ill Patients and Families
Thrive through an ABCDEF Approach” p10
2. Everything is at least 2-3 times worse with
Moderate to Severe AKI
50% of patients in the ICU will develop
some stage of Acute Kidney Injury (AKI)
LOS
Hospital
Cost
30-Day
Readmission
Hospital
Mortality
16 days
11 days
5 days
28.6%
21.8%
9.3%
$52,600
$38,900
$18,500
1x
2x - 3x
Greater
5x - 11x
Greater
2x 3x
2x 4x 6x 8x 10x 12x
26.0%
12.9%
2.3%
Short-term & long-term consequences
associated with increasing AKI severity
LOS3
: Total postoperative length of stay (days/patient);
Hospital Cost3
: Total postoperative cost (US$/patient); 30-Day
Readmissions4
: Percent of postoperative patients; Hospital
Mortality3
: Percent of postoperative patients.
No AKI Moderate Severe
[1] McCullough P, et. al. Contrib Nephrol. 2013;182:13-29.
[2] Mandelbaum T, et. al. Crit Care Med. 2011;39(12):2659-2664
Acute Kidney Injury is an increasingly common and potentially devastating complication in hospitalized individuals.1
Studies suggest
that approximately half of all patients admitted to the ICU will develop some stage of Acute Kidney Injury.2
If a patient develops an AKI
complication during hospitalization, short-term and long-term consequences could be twice as severe, such as length of stay (LOS),3
hospital
cost,3
30-day readmissions4
and hospital mortality.3
[3] Dasta J, et. al. Nephrol Dial Transplant. 2008;97(1):1970- 1974
[4] Brown J, et. al. Ann Thorac Surg. 2014;97(1):111-117
[5] Martensson J, et al. Brit J Anaesth. 2012;109(6):843-50.
The NephroCheCk®®
® Test System is intended to be used in conjunction with clinical evaluation in patients who currently have or have had
within the past 24 hours acute cardiovascular and or respiratory compromise and are ICU patients as an aid in the risk assessment for
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The NephroCheCk®®
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factor binding protein 7 (IGFBP-7) - and combines them into a single AKIRISKª Score. Both biomarkers are thought to be involved in G1
cell-cycle arrest during the earliest phases of injury to the kidney.6
[6] Kashani K, et. al. Crit Care. 2013;17:R25
�2015 Astute Medical, Inc. Astute Medical®, the AM logo, Astute140®, NephroCheCk�®
and the NephroCheCk�®
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About/IntellectualProperty. PN 0459 Rev B 2015/07/28.
The challenge is that acute kidney injury (AKI) is difficult to identify early1
and delays in
recognizing AKI can lead to irreversible damage and high mortality5
�
NOW AVAILABLE
A first of its kind
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4. 4 | August/September 2015 +1 847 827-6869 Critical Connections
President’s Message
Creating a Better Tomorrow
“So...this is the new normal.”
Those were the words I heard recently from a survi-
vor in the surgical/transplant intensive care unit (ICU)
I work at in Emory University Hospital. It was National
Nurses Week, and every day, there was another event to
celebrate our nursing staff, who are the heart and soul
of our ICU. The final day of celebration was to be both
the most sobering and the most amazing.
A woman that we had taken care of a year and a half
earlier had come back to speak to us. She had suffered
acute hepatic failure and had spent over a month with
us as a patient and now was returning to tell her story
and answer questions from our staff. Each of us had
taken care of her in the long days and weeks when she
was ill. Yet, aside from conversations with her family, we
had never seen her a healthy person. (Some, perhaps
sadly, only saw her as “the acute hepatic” and not as a
person at all.) Certainly, the vast majority of us had no
idea what happened to her after she left the ICU. As
always happens, there was another patient who needed
our care, and our attention shifted elsewhere.
Yet this morning, during National Nurses Week, we
all had the opportunity to pause, to hear directly from
our former patient and to reflect on both the triumph
and unrecognized downside of what we do. Prior to
her hospitalization, she was generally healthy. She had
a steady job. She went out with her friends. She had a
loving significant other and loving parents. Suddenly,
critical illness struck.
Thankfully, she remembers fairly little of her ICU
course. Her loved ones remember her not waking up
for days and the question about whether her cerebral
edema was so severe that she might never wake up. Her
loved ones also remember the amazing care she got
from our entire staff, who were with her day and night.
Her memories are, of course, quite different. Perhaps
not unexpectedly, her memories of the ICU are hazy
and somewhat disjointed. Some moments stand out
clearly, some are vague and some never happened even
though they felt real to her in an encephalopathic and
delirious state.
Eventually, she was strong enough to leave the ICU.
When she left the hospital, no one told her to expect
life to be different, so she simply went back to work.
And she rapidly found that she couldn’t work full-time
anymore. Mentally, concentrating for hours at a time
simply wasn’t possible. Even previously simple tasks
took Herculean effort. Just thinking made her tired to
the point that she would need to sleep for extended
periods of time that she never had before. Fine motor
skills had abandoned her. Even now, she cannot open a
soda can on her own. Food tastes different. She is more
emotional. And more than a year later, she has night-
mares she cannot shake. There is, of course, tremen-
dous richness in her life but it is not the same. She and
her loved ones have adjusted to this new life, but, even
as a “lucky” one who survived a brush with death, the
reminders are everywhere that life is not what it used to
be and may not ever fully be.
After hearing this amazing story, we started asking
questions. In retrospect, what does she wish we had told
her? “It doesn’t end when you leave the ICU. And it won’t end
when you leave the hospital. You suffered a major injury, and it
will take a long time to continue your healing.” Did she know
that others had similar issues to her? “No.” Had she ever
heard of post-intensive care syndrome (PICS)? “No.”
Would it have helped to know this? “Absolutely.” Would a
support group of others going through similar issues be
helpful? “Yes!”
I have previously written about SCCM’s new
THRIVE Initiative in this space. While we have done
a remarkable job taking care of the patient in the bed
in front of us, we have frequently not recognized what
happens to the person lying in that bed when they are
no longer our patient. But that is changing. With our
new attention to PICS, new research into PICS, and
new support groups for PICS, we hope to transform the
post-ICU experience. One day, I hope we will under-
stand enough about the causes of PICS that we can
prevent it totally. Until that day, our THRIVE Initiative
is intended for those who have “a new normal,” so that
they know they are not alone. So that they know that
together, we can create a better tomorrow for those who
survive the ICU.
With our new attention to
PICS, new research into PICS,
and new support groups for
PICS, we hope to transform
the post-ICU experience.
Craig M. Coopersmith, MD, FCCM, is a professor of
surgery and Vice Chair of Research, Emory University
School of Medicine; Associate Director of the Emory
Critical Care Center; and director of the surgical/transplant
intensive care unit at Emory University Hospital.
@SCCMPresident.
Business Line Update
It is our pleasure to detail the products and services that
constitute the Knowledge and Skills Business Line. Most
of you will interact with the Society of Critical Care
Medicine (SCCM) through this line. We wanted to let
you know about some key features and exciting updates
by area, as led by SCCM staff partners Pam Dallstream
and Kerry Copeland.
Congress Program: Rich Branson and John Kellum
will serve as Program Co-Chairs for the annual Congress
in Orlando on February 20-24, 2016. Expect high qual-
ity pre- and post-Congress courses (ECMO, Ultrasound,
Airway Management, Hemodynamic Monitoring, and
Mechanical Ventilation) and main session offerings
that will allow participants to earn Maintenance of
Certification (MOC) credits. This year, member partici-
pation in program content has been strengthened and
onsite interaction between speakers and the audience
will be a highlight. Plenary speakers include: Derek C.
Angus, Jean-Louis M. Vincent, Jay A. Johanningman,
James S. Merlino, Maurene A. Harvey, Brian L. Erstad,
and Lewis A. Rubinson. In addition, traditional poster
presentations will be converted to a digital format. (More
details to follow.) Plan on attending with members of
your multiprofessional team!
Current Concepts Courses: Save the dates (February
19-20, 2016) for these pre-Congress events and learn
cutting edge (and key refresher) concepts in critical care.
Edward Bittner (adult) and David Turner (pediatric),
along with their hard working committee members and
SCCM staff partner Katie Caracci, are busily prepar-
ing 20 hours worth of content for each course. This is
a super easy way to get updated and earn continuing
medical education/continuing education credits. Check
and check!
ECMO Management: Following Congress (in Tampa,
Florida, on February 25-26, 2016), you are encouraged
to participate in a comprehensive overview of adult
and pediatric extracorporeal membrane oxygenation
(ECMO) in an intense two-day simulation course. Each
simulation group will have a maximum of 10 partici-
pants and two facilitators. Led by course director Heidi
Dalton and SCCM staff partner Jerry Price, the course
will train you well in the basic physiology of ECMO,
equipment and patient selection, and economic and
ethical considerations. This course is held in conjunc-
tion with the Extracorporeal Life Support Organization
(ELSO).
One of the aims of Critical Connections is to keep the
membership informed about the Society’s myriad of
activities and initiatives. Toward that end, a different
Business Line leader will use this space each issue to
provide updates about the undertakings and priorities
of their respective Business Line.
Knowledge
and Skills
Business Line
5. Critical Connections
Grand View Hospital
Sellersville, PA
Intensivist Physician
u 202 bed hospital / 14 ICU beds
u 40 miles north of Philadelphia
Raritan Bay Medical Center
Perth Amboy and Old Bridge, NJ
Intensivist Physician
u Perth Amboy- 300 bed hospital /20 ICU beds
u Old Bridge -180 bed hospital / 10 ICU beds
u Area leader in cardiovascular care
St. Francis Hospital
Wilmington, DE
Intensivist Physician
u 214 bed hospital / 14 ICU beds
u 40 minutes outside of Philadelphia
St. Luke’s Cornwall Hospital
Newburgh, NY
Intensivist Physician
u 240 bed hospital / 18 ICU beds
u Newest Emergency Department in the region
Join a Critical Care Leader
■ theintensivistgroup.com/employment
Contact Cathy Harbert, Director of Recruiting, at 330.418.2226 or by email at CHarbert@theintensivistgroup.com
Critical care… the way it should be
• Strong collegial teamwork
• Innovative clinical leaders
• Evidence-based, data-driven clinical practice
• Sustainable career with leadership development
• Access to:
º SoundLink Concierge service
º Sound Institute learning development and no-cost CME
Saint Francis Memorial Hospital
San Francisco, CA
Program Medical Director
u 359 bed Dignity Health hospital
u 18 ICU beds
Regional Medical Center of San Jose
San Jose, CA
Intensivist Physician
u 216 bed hospital / 34 ICU beds
u Accredited by The Joint Commission
St. Bernardine Medical Center
San Bernardino, CA
Intensivist Physician
u 342 bed hospital / 32 ICU beds
u Easy access to all of Southern California
West
East
Delnor Community Hospital
Geneva, IL
Program Medical Director Intensivist Physician
u 159 bed hospital/10 ICU beds /9 step-down beds
u Beautiful Chicago suburb along the Fox River
Mercy Hospital Anderson
Eastern suburb of Cincinnati, OH
Program Medical Director
u 18 ICU beds and inpatient pulmonary consult
u Inpatient pulmonary / critical care program
SSM St. Mary’s Health Center
St. Louis, MO
Intensivist Physician
u 525 bed hospital / 24 ICU beds
u Teaching hospital in metro St. Louis
Midwest
Florida Hospital Tampa
Tampa, FL
Intensivist Physician
u 475 bed hospital / 36 Med-Surg ICU beds
9 CCU beds / 8 Cardiothoracic ICU beds
u Tertiary hub for 5 hospitals in health system
Southeast
Ultrasound Offerings: The adult version of the
SCCM critical care ultrasound course is offered prior
to Congress (February 19-20, 2016) and is led by course
director Mark Hamlin. The pediatric critical care
ultrasound course will be held prior to Congress as well
(February 19-20, 2016) and is led by course director Erik
Su. Register quickly as these courses sell out! Several
additional updates in the world of SCCM ultrasound
should be mentioned. The Advanced Practice Providers
Ultrasound Task Force has been absorbed by the adult
and pediatric committees with adoption of practices
and instructors to make the courses more applicable
to advanced practice providers (more time on vascular
access skills stations). A textbook reinforcing material
taught in the adult and pediatric courses will be available
later this year with current and former ultrasound course
directors and instructors Sam Brown, Mike Blaivas, Ellie
Hirshberg, Jan Kasal, and Aliaksei Pustavoitau serving as
editors. Additionally, international sites can now export
the basic and advanced adult ultrasound courses to their
facilities using an SCCM-approved course director. The
first such course, expertly directed by Andrew Patterson,
was held in the United Arab Emirates in April 2015.
Another was held in Peru in August 2015, and future
ones are planned in Central and South America in the
near future. Additionally, led by SCCM staff partner
Jerry Price, SCCM is in discussions with several organiza-
tions to address personal certification and institutional
accreditation for basic and cardiac ultrasound. This work
should facilitate hospital credentialing and address billing
concerns held by our members. Finally, expect the pub-
lication of guidelines regarding the use of ultrasound by
Critical Care Medicine sometime this fall.
Heidi L. Frankel, MD, FCCM, is a member of SCCM Council
and leads the Knowledge and Skills Business Line.
Lauren Sorce, ACNP, CCRN, FCCM, is Pediatric CC NP/
APN Manager at Ann Robert H. Lurie Children’s Hospital of
Chicago in Chicago, Illinois, USA. She is a member of SCCM
Council and leads the Knowledge and Skills Business Line.
Critical Connections Seeks
Your Thoughts, Insights and
Success Stories
Critical Connections editor, Sandra L. Kane-Gill,
PharmD, MS, FCCM, wants to hear from readers with
their insights, ideas and success stories centered on
several topics that have been or will be featured this
year. Give us a window into your daily practice by
sharing items such as your guideline implementation
success stories, your new patient-centered care
initiatives or your team’s approach to targeted
temperature management.
Specifically, the topics include: cardiac arrest and
targeted temperature management; patient and family
outreach and care; implementation of the Surviving
Sepsis Campaign guidelines; and implementation of
the pain, agitation and delirium (PAD) guidelines.
Select posts will be shared with the critical care
community via the Society’s various communications
channels, including upcoming issues of Critical
Connections. Visit www.sccm.org/eCommunity for
more information.
Mechanical Ventilation Textbook: Look out for
publication of this work in 2016 by expert editors Neil
MacIntyre, John Marini and Ira Cheifetz. Katie Brobst
is the SCCM staff partner. This book will include both
adult and pediatric considerations in management.
Learn ICU: Where can you find articles, slide sets, pod-
casts, and lectures grouped by topic area? The Society’s
LearnICU.org website is undergoing major upgrades
under the direction of Suresh Agarwal and SCCM staff
partner Melissa Nielsen. The upgraded site will include
enhanced search capabilities and more robust knowledge
sharing features.
More information about all of these products and ser-
vices is available at www.sccm.org.
6. 6 | August/September 2015 +1 847 827-6869 Critical Connections
Advancements in critical care have decreased mortality
and resulted in an increased probability of living through
even the most serious illnesses.1-3
The Society of Critical
Care Medicine has recently termed the combination of
physical deficits such as impaired pulmonary function and
neuromuscular weakness, neurologic and psychological
morbidities such as cognitive dysfunction and posttrau-
matic stress disorder (PTSD), and overall poor health-
related quality of life as post-intensive care syndrome
(PICS).4,5
Survivors with PICS are frequently trapped in a
cycle of recurrent illness and rehospitalization after being
in the intensive care unit (ICU) and have increased mor-
tality.6
Few reach their goal of full recovery.7-11
The estab-
lishment of an ICU follow-up clinic has been proposed
as one way to minimize and manage long-term complica-
tions for these patients. The goals of a PICS clinic include
optimization of cognitive, physical, and psychological
function following critical illness, improved care coordina-
tion, and decreased healthcare utilization.
There is no one consistent model of a PICS clinic.
Nurse-led clinics have been in evidence in Europe since
the 1990s. However, this has not been a consistent model
of care in the United States. In 2012, The ICU Recovery
Center at Vanderbilt was established to explore the feasi-
bility and effectiveness of an ICU follow-up program and
represents one potential model of ICU follow-up. Our
team consists of an acute care nurse practitioner, a critical
care pharmacist, a neuropsychologist, a pulmonary criti-
cal care physician, and a case manager. The role of these
providers within the clinic is unique in that it combines
the perspectives of both inpatient and outpatient practi-
tioners and attempts to bridge the gap between intensive
care and the outpatient setting, with the ultimate goal of
full recovery for patients and their families. The elements
of our program were initially established based on the
problems we were seeing in survivors of critical illness
and the concerns that these survivors and their families
reported to us. These elements have been refined over the
past three years and are described herein:
1. A formal medical examination is provided during the
visit. First, spirometry and six-minute walk testing
are performed to screen for respiratory and airway
sequelae, as well as persistent critical illness myopathy.
A structured interview is then conducted by a critical
care nurse practitioner to review the patient’s hospital
course and any current physical complaints or prob-
lems. The physical examination is focused on sequelae
related to critical illness, including but not limited to
tracheostomy, respiratory failure, indwelling vascular
catheters, weakness, and skin breakdown.
2. The pharmacist completes a thorough medication
reconciliation, drug therapy review, evaluation of side
effects, patient counseling, and promotion of medica-
tion adherence. Barriers to medication adherence,
including cost and lack of assistance tools, are then
targeted, with the goal of improving adherence and
minimizing adverse medication-related events.
3. A cognitive and mental health evaluation is performed
by a neuropsychologist to screen for problems com-
mon in ICU survivors, including cognitive dysfunction,
depression, and PTSD. Global cognitive functioning,
executive functioning and attention are evaluated with
the assistance of several widely available instruments,
including the Montreal Cognitive Assessment (MoCA)12
and the Trail Making Test (TMT) Parts A and B.13
Depression is assessed with the Hospital Anxiety and
Depression Scale (HADS)14
or the Beck Depression
Inventory®-II (BDI®
-II),15
and PTSD screening is
done with the Posttraumatic Stress Disorder Checklist
(PCL).16
Findings from this brief screening are used in a
patient-centered assessment, with the results and impli-
cations explained to the patient, at which time patient
feedback is solicited.17
4. Case management has been shown to positively impact
diverse outcomes, including hospital readmission rates
and disease management.18,19
A brief case manage-
ment consultation is conducted to screen for missing
services and to link the patient to relevant resources,
including community mental health and fitness. A case
manager is often needed to arrange home care and
durable medical equipment. Further, a case manager
can review how to access resources such as after-hours
clinics and express care that may save the patient a trip
to the emergency department and potentially prevent
readmission. If the patient does not have a primary
care provider, a case manager can assist the patient
in establishing a relationship with such a provider.
A final consultation with patients and their
families, wherein an intensivist summarizes the
hospital course, physiologic testing performed
during the visit, and any problems identified, is a
useful conclusion to this interdisciplinary visit. New
and persistent diagnoses, the treatment plan, additional
specialist referrals, and medication changes are reviewed.
Patients and family members are given the opportunity to
Clinical Spotlight
It Takes a Team: Contributions of Each Team
Member in a Post-Intensive Care Syndrome
Clinic Model
ask questions. A survivorship care plan (SCP), based on
those used in the cancer survivorship arena but tailored
to address the unique needs of patients after critical ill-
ness, is also shared with the patient at this time. The SCP
includes contact information for the care team, basic
historic health information, detailed information about
the patient’s critical illness course, a list of medications,
and specific recommendations for follow-up care with
timelines. Often, the period after critical care is a teach-
able moment in which the patient is open to significant
lifestyle changes that have the potential to improve health
and maintain recovery, such as smoking cessation or pre-
ventative immunization, and these are addressed in our
model by a physician familiar with the patient’s critical
care course.
Other attempts to improve the post-ICU period have
included additional disciplines such as physical therapy,
occupational therapy, and palliative care. The team mem-
bers required may vary based on the healthcare setting
and the resources available.
As the number of patients admitted to ICUs and
surviving increases, the importance of recognizing and
treating PICS grows as well.4,6
Although its effectiveness is
yet to be proven, an interdisciplinary PICS clinic is a logi-
cal, feasible way to treat this syndrome. Each member of
the PICS team plays an integral role in providing care to
patients and family members. Further research is needed
to evaluate the impact of PICS clinics on outcomes for
ICU survivors and their families.
References and disclosures are available at
www.sccm.org/criticalconnections.
Elizabeth L. Huggins, AG-ACNP, is an acute care nurse
practitioner in the Medical Intensive Care Unit and The ICU
Recovery Center at Vanderbilt University Medical Center in
Nashville, Tennessee, USA.
Joanna L. Stollings, PharmD, BCPS, is a clinical pharmacy
specialist in the Medical Intensive Care Unit and The ICU
Recovery Center at Vanderbilt University Medical Center in
Nashville, Tennessee, USA.
James C. Jackson, PsyD, is a neuropsychologist and the
assistant director of The ICU Recovery Center at Vanderbilt
University Medical Center in Nashville, Tennessee, USA.
Carla M. Sevin, MD, is an assistant professor of medicine
and the director of The ICU Recovery Center at Vanderbilt
University Medical Center in Nashville, Tennessee, USA.
7. Critical Connections www.sccm.org August/September 2015 | 7
Advances in technology and medicine have reduced
mortality rates and extended the lives of thousands of
critically ill patients. These advances have shifted the con-
cern from survival to quality of life and preservation of
function, including cognitive functioning, mental health
functioning and physical functioning. As others have
observed, the metabolic derangements and perturbations
associated with critical illness and intensive care unit
(ICU) hospitalization often cast a long shadow; prelimi-
nary data suggest that the sequelae of critical illness rep-
resent a significant public health concern.1
For example,
evidence suggests that more than half of ICU survivors
have cognitive impairment,2
approximately a third have
depression,3
and up to 20% have posttraumatic stress dis-
order.4
Physical debility is also common.5
Collectively, the
constellation of problems experienced by ICU survivors is
referred to as post-intensive care syndrome (PICS). Methods of
preventing the development of this condition have yet to
be identified.6
One promising approach involves evalua-
tion of patients in PICS clinics, particularly in the early
post-discharge period.
Although PICS was not an existing clinical entity at the
time, the development of clinics to address patients’ chal-
lenges after intensive care treatment began in the United
Kingdom more than 20 years ago.7
(The first clinic was in
Reading, United Kingdom, in 1993.) During the past 15
years, many more clinics have emerged across the United
Kingdom and Australia. More than half of them are run
by nurses, and most of them treat only patients who had
ICU stays of more than three days. Roughly one-third
of these clinics have access to psychology and physical
therapy services for their patients.8
Although effectiveness
data are lacking, patient satisfaction with this model of
care has been high.9-11
Building on the success of follow-up clinics in the
United Kingdom, the first PICS clinic in the United
States was established in 2011 by the pulmonary/criti-
cal care and geriatrics divisions at the Indiana University
School of Medicine. The Critical Care Recovery Center
(CCRC) focused on delivering collaborative care to ICU
survivors, specifically targeting geriatric patients with
depression and psychological disorders.12
Its goals were
similar to those of the European clinics: improve patient
outcomes after ICU discharge, address PICS using a mul-
tidisciplinary team, decrease readmission rates and mor-
bidities, and improve the quality of life for patients after
critical illness. Patient recruitment was focused on adult
patients who had spent more than 48 hours on mechani-
cal ventilation or had had delirium for more than 48
hours. The CCRC was designed to have two assessment
phases and then follow-up visits, with a staff that included
registered nurses, social workers and physicians.12
In 2012, Vanderbilt University opened the second PICS
clinic in the United States, The ICU Recovery Center.
Much like the CCRC, the Vanderbilt PICS clinic takes
a multidisciplinary approach to improving the long-term
outcomes of patients after ICU discharge. These out-
comes include pulmonary functioning, overall physical
health, cognitive functioning and mental health, medica-
tion safety and reconciliation, and the degree of return
to basic daily function. Patients referred to the clinic
are recruited from all adult ICUs and are screened and
tracked by the clinic team during hospitalization. Eligible
patients include adults with severe acute respiratory
distress syndrome, sepsis, delirium, and those requiring
mechanical ventilation.
Although many of our observations to date are anec-
dotal, we have found that it is most beneficial for patients
to be evaluated in the clinic after they have been home for
two to four weeks. The clinic is staffed by a critical care
pulmonologist, a clinical pharmacist, a neuropsychologist,
an acute care nurse practitioner, and a nurse case man-
ager. The clinic visit lasts one to two hours and includes
pulmonary function tests, a six-minute walk test, a full
history and physical examination, a medication review,
a neurocognitive examination, and a meeting with a
case manager. The clinic visit provides an opportunity to
identify the ongoing needs of the patient and frequently
results in referrals for physical therapy and medical sub-
specialty clinics, as well as discussions about work re-entry
or end-of-life care, among other topics. At the conclusion
of each clinic visit, the team discusses each aspect of the
patient’s recovery and prepares a letter summarizing its
findings and recommendations for the patient’s primary
care provider.
Both the CCRC and the Vanderbilt PICS clinic have
sought to improve long-term outcomes, decrease hospi-
tal readmission rates and decrease morbidity associated
with PICS; however, there continue to be barriers to
effective post-ICU care. In our experience, two promi-
nent obstacles are the availability of adequate resources
and the logistic challenges of recruiting patients. For a
PICS clinic to identify and treat the problems associated
with critical illness, basic resources are required, such as
pulmonary function testing, laboratory capabilities, and a
complement of multidisciplinary providers.
The process of recruiting patients who may benefit
from a PICS clinic and tracking them through an often
long and complicated hospital stay is time consuming.
Patients are frequently transferred from the ICU to a
step-down unit, where they may stay for weeks before
being discharged to a rehabilitation facility and ultimately
going home. Recruitment is also challenging at times
because some patients feel overwhelmed by the number
of providers they have (or simply do not want to travel
back to the hospital) and are thus lost in follow-up. Many
of these barriers can be addressed with additional funds,
resources and personnel. The recruitment process can be
improved and streamlined with both a local champion
(usually a physician leader who actively advocates for
participation in the clinic) and a dedicated staff member
who is able to recruit, track and refer patients on a daily
basis. The electronic medical record holds promise here;
in many settings these types of logistic challenges can be
overcome with electronic tracking, ordering, and schedul-
ing. The process of patient and family participation can
be improved by helping ensure that patients are fully
educated about the sequelae that may result from critical
illness; once they understand the range of difficulties that
survivors of critical illness may encounter, they are often
highly motivated to attend a post-discharge clinic. This
education optimally occurs in a face-to-face context and
Clinical Spotlight
Models for a Post-Intensive Care Syndrome
Clinic: Targeted Goals and Barriers
may be aided by information materials such as brochures
that describe the problems represented by PICS.
As the number of patients who survive an ICU admis-
sion grows, PICS clinics have the potential to become an
important part of post-ICU care. There is no standard
model that directs the development of PICS clinics, but
with more funding and research, outcomes will be mea-
sured, and goal-directed, evidence-based models will be
created.
References and disclosures are available at
www.sccm.org/criticalconnections.
Elizabeth L. Huggins, AG-ACNP, is an acute care nurse
practitioner in the Medical Intensive Care Unit and The ICU
Recovery Center at Vanderbilt University Medical Center in
Nashville, Tennessee, USA.
James C. Jackson, PsyD, is a neuropsychologist and the
assistant director of The ICU Recovery Center at Vanderbilt
University Medical Center in Nashville, Tennessee, USA.
Joanna L. Stollings, PharmD, BCPS, is a clinical pharmacy
specialist in the Medical Intensive Care Unit and The ICU
Recovery Center at Vanderbilt University Medical Center in
Nashville, Tennessee, USA.
Carla M. Sevin, MD, is an assistant professor of medicine
and the director of The ICU Recovery Center at Vanderbilt
University Medical Center in Nashville, Tennessee, USA.
The Need for PICS Clinics
Below are critical care patient and family member
comments collected by Vanderbilt University Medical
Center that underscore the implicit need for PICS
clinics. Many of the comments capture the frustration
and anxiety patients experience after ICU discharge.
“The day you’re discharged is the day care
ends.”
“When they knew I was going to make it, it
was like, ‘Okay, we’ve done our job here.’”
“My primary care physician, like all physicians,
is overwhelmed. I don’t think they get any
feedback from the hospital about what went
on.”
“You’re a different version of you. But people
can’t see your injury. They expect you to go
back to how you were before.”
9. Critical Connections www.sccm.org August/September 2015 | 9
Francois Aspesberro, MD, is an assistant professor in
Pediatric Critical Care Medicine at Seattle Children’s Hospital
and at Harborview Medical Center (University of Washington)
in Seattle, Washington, USA.
Melanie Kitagawa, MD, is a fellow in pediatric critical care
medicine at Texas Children’s Hospital and Baylor College of
Medicine in Houston, Texas, USA.
Carley Riley, MD, MPP, MHS, is an assistant professor in
the Department of Pediatrics, Division of Critical Care Medicine
at Cincinnati Children’s Hospital Medical Center.
Jerry Zimmerman, MD, PhD, FCCM, is a professor in
Pediatric Critical Care Medicine and Anesthesiology at
Seattle Children’s Hospital and at Harborview Medical Center
(University of Washington) in Seattle, Washington, USA.
How common and severe is PICS? The evidence keeps
accumulating. For example, growing data show that one
year after critical illness, 24% of survivors experience
cognitive impairment that mimics mild Alzheimer disease5
;
20% to 30% of survivors report disabling symptoms of
anxiety, depression or post-traumatic stress disorder6,7
; and
30% of survivors suffer from disabilities in the activities
of daily living.8
In addition, many survivors are unable to
return to work,9
and the need for post-acute healthcare use
and an increased risk of hospital readmission are all too
common consequences.10-12
These changes exact a social
and financial toll and serve as a barrier to a meaningful
recovery.
We have also learned that an apparent gap exists
between what survivors need and what they receive.13,14
Survivors and their caregivers have shared that education,
preparation and support are essential during recovery
and that these needs extend well beyond hospital
discharge.13-15
Yet, while ICU culture has transitioned to
fostering collaboration with our patients and caregivers,16
issues of survivorship are rarely addressed during ICU
stays.17
Although a number of distractions try to tear us away
from our core mission of the Right Care, Right Now™
for our critically ill patients, PICS is not a distraction.
Here are our top five reasons why we believe PICS is, in
fact, at the center of our mission of clinical excellence for
the critically ill.
1. Our Patients Care about PICS
First and foremost, our patients care about long-
term outcomes. While survival is the primary goal for
patients and their loved ones, survivors highlight that
neuropsychological and physical function are important
patient-centered outcomes. Impairment in these domains
is disruptive and life-altering.13-15
Moreover, for some,
healthcare that results in cognitive or physical impairment
may be less desirable than death.18
2. Most Patients Survive
Each year, in the United States alone, nearly six million
patients are admitted to an ICU.19
Driven by care
advances, short-term mortality after critical illness has
never been lower. The result is that an estimated five
million survivors of critical illness are discharged into our
communities. Many of these survivors will be impaired in
some way. These impairments frequently go unrecognized,
and they have an impact that extends beyond the
survivors.20,21
3. It Is the Future of Medicine
In the near future, healthcare systems will be evaluated
on the care provided over a patient’s cycles of care.22,23
Fortunately, the incentive to deliver coordinated
longitudinal care aligns with how patients view their own
health narratives.13-15
As a result, strategies designed to
mitigate long-term impairment, to prepare survivors and
their loved ones for what to expect after critical illness, and
to effectively coordinate care from the ICU to follow-up are
precisely where efforts should be focused as we transition
from understanding the survivor’s experience to figuring
out how to ensure an enduring recovery.
4. It Will Help Us Grow
Caring about PICS is ultimately about reintegrating critical
care into the longer-term trajectory of a patient’s life. This
has always been one of the great joys of critical care—the
intensity with which we share patients’ and families’ lives in
these moments of crisis and the satisfaction that resulted.
“Why ICU Clinicians Need to Care about Post-Intensive Care Syndrome” continued from p1
But we have historically been limited in our evidence base,
lacking data on how to change our practice to achieve
better lives for our patients.
To accelerate this process and to ensure that efforts are
in line with the patient’s experience and needs, SCCM’s
THRIVE Initiative proposes a partnership of healthcare
providers, patients and families. This concept, championed
as a “creative disruption of medicine,”24,25
puts patients
and their families in the driver’s seat. The expectation is
that novel solutions will emerge to improve the care of, and
recovery from, critical illness.
5. We Can Make It Better
Lastly, we can do something about PICS. For years we
were hamstrung by the lack of an evidence base, but that
has changed in the last decade. In particular, two SCCM
initiatives may fundamentally reduce the burden of PICS
for our patients and families.
The ICU Liberation Initiative represents the state of
the art in preventing PICS and embraces the element of
family engagement and empowerment. This initiative
will invigorate the effective implementation of the 2013
American College of Critical Care Medicine’s “Clinical
Practice Guidelines for the Management of Pain,
Agitation, and Delirium in Adult Patients in the Intensive
Care Unit” across the United States.
THRIVE takes the proverbial baton, leverages the
principles espoused in the ABCDEF bundle championed
within the ICU Liberation Initiative to mitigate long-term
impairment, and focuses on life after critical illness. At
its boldest, THRIVE intends to partner with survivors to
change the trajectory of recovery after critical illness. It is
about changing the experience of survivorship from one
that revolves around impairment to one that focuses on
recovery. Ultimately, the multiphase plan expects to: build
a network of in-person support groups, where survivors
can help each other recover more effectively; discover and
disseminate effective strategies for effective survivor-led
support groups; complement these in-person activities with
an Internet presence; educate non-ICU clinicians on PICS;
and stimulate new knowledge about recovery.
In conclusion, we have learned that many survivors
of critical illness experience long-term consequences.
This realization affords us the opportunity to shift our
perspective—and consequently our practice—to a horizon
beyond the walls of the ICU. For that, we should all be
grateful.
References and disclosures are available at
www.sccm.org/criticalconnections.
Theodore J. Iwashyna, MD, PhD, is an associate professor
of medicine at the University of Michigan in Ann Arbor,
Michigan, USA.
Mark E. Mikkelsen, MD, MSCE, is an assistant professor
of medicine at the University of Pennsylvania in Philadelphia,
Pennsylvania, USA.
Carol Thompson, PhD, ACNP, CCRN, FCCM, is a professor
at the College of Nursing at the University of Kentucky in
Lexington, Kentucky, USA.
ficulties. Psychological support may improve outcomes
for children and parents. Further research is essential to
establish the timing, extent and type of psychological
support that is best to support these children and their
families.
Remembering the Burden on Caregivers and Families of
PICU Survivors
Critical illness and its outcomes affect not only our
patients but also their families; consequently, we must
also care for the families. Importantly, PICS is not
limited to patients. The families and caregivers of PICU
survivors have an increased risk of mental health dis-
orders, such as anxiety, depression and PTSD.9
Caring
for a child who has new or worsened morbidities after a
PICU stay may result in strain on relationships, increased
anxiety and depression, and distress about caring for
other children.9-11
These struggles are magnified if
the caregiver is a single parent or has limited finan-
cial resources.10,11
Risk factors for increased caregiver
burden in adult ICU survivors include being female,
living with the care recipient, and lacking a choice in
being a caregiver.12
Families of PICU survivors likely
have similar risks for increased caregiver burden. As we
begin to address long-term outcomes for our patients,
we also need to address long-term outcomes for their
families. There is a need to understand the risk factors of
increased caregiver burden and worsened family dynam-
ics that PICU survivor families face so that we can then
begin to find appropriate support and care for these
families.
A “good save” is no longer good enough.13
Pediatric
intensivists need to look beyond the doors of the PICU
and hospital, because maximizing quality of life should
ultimately be our most important goal.
References and disclosures are available at
www.sccm.org/criticalconnections.
10. 10 | August/September 2015 +1 847 827-6869 Critical Connections
“Helping Critically Ill Patients and Families Thrive through an ABCDEF Approach” p1
The Choosing Wisely®
initiative, aimed at helping
patients choose care that is supported by evidence, free
from harm and truly necessary, has also helped generate
a national dialogue on the potential long-term hazards of
some routinely applied ICU practices. For example, one
of the first Choosing Wisely®
recommendations related
to critical care is, “Don’t deeply sedate mechanically ven-
tilated patients without a specific indication and without
daily attempts to lighten sedation.” Additional infor-
mation about this recommendation is available at www.
choosingwisely.org/?s=mechanically+ventilated.
One strategy for incorporating the 2013 PAD guideline
recommendations into everyday care, and thus potentially
reducing the incidence of PICS, is the newly modified
ABCDEF bundle, comprising the following components:
Assess, prevent, and manage pain; Both spontaneous
awakening trials and spontaneous breathing trials; Choice
of analgesia and sedation; Delirium: assess, prevent, and
manage; Early mobility and exercise; and Family engage-
ment and empowerment. (See Figure 1.3-5
) The individual
components of the ABCDEF bundle (www.icudelirium.
org) are evidence based and were recently shown to be
safe and effective when incorporated into everyday care.6
They are recommended by a number of national patient
safety and quality organizations, such as the Institute
for Healthcare Improvement. One of the strengths of
the ABCDEF bundle is that the individual interventions
are straightforward and clearly defined (e.g., a suggested
safety screen and pass/fail criteria). The bundle is also fle-
xible, enabling each institution to tweak the interventions
to meet the unique needs of its patients and its own cul-
ture. Above all, the bundle highlights the importance of
assessing, preventing and managing pain while engaging
and empowering patients’ family members to advocate
for successful ABCDEF delivery.
Significant ABCDEF bundle implementation challen-
ges remain. One possible reason for the delay in imple-
mentation is that some institutions use some, but not all,
of the interventions, expecting dramatic improvements in
patient outcomes. Interventions comprising the ABCDEF
bundle are interrelated and interdependent. For example, a
patient who is deeply sedated cannot be mobilized, and
medication cannot be titrated to a light level of sedation
without the sedation level first being reliably assessed.
Additionally, implementation of the ABCDEF bundle
requires multiple members of the healthcare team to
collaborate and coordinate care activities. The ABCDEF
bundle is a tool. Effective implementation requires
acknowledgment of the interconnectedness of the peo-
ple, processes, and evidence5
involved. (See Figure 2.5
)
Unfortunately, until recently, more emphasis was placed
on the science behind the bundle and less on the impor-
tance of these human and system factors.
SCCM has launched an ICU Liberation collaborative
related to implementing the PAD guidelines via appli-
cation of the ABCDEF bundle. Through the generous
support of the Gordon and Betty Moore Foundation, 76
U.S. hospital ICUs in three different regions will work
with a team of leading national and regional experts to:
• Optimize pain control plus reduce sedative exposure
and time on mechanical ventilation
• Improve time patients are free of delirium and coma
• Improve a team approach to early mobilization
• Engage families to participate in the care and healing of
their loved ones
• Validate compliance and improvement through use of
an online data collection tool
• Enhance teamwork through implementation of eviden-
ce-based care
• Engage with leading experts who have demonstrated
improved patient outcomes through the ABCDEF
bundle
• Create partnerships with other institutions doing the
same improvement work across the United States
This multi-institutional partnership will substantially
advance understanding of the potential patient- and
family-centered benefits of reliable ABCDEF bundle
adoption. The collaborative will seek to better understand
the organizational, unit-level, and profession-specific
factors associated with bundle compliance and facilitators
and barriers to optimal team performance, communica-
tion, and a healthy work environment.
While the effect of reliable ABCDEF bundle adop-
tion on the incidence and outcomes of PICS has yet to
be fully studied, intuitively it is an extremely promising
approach. For example, effectively managing critically
ill patients’ pain and avoiding oversedation may lead to
increased cognitive engagement and improved physical
activity, thus reducing the risk for ICU-acquired weakness
and the many mental health problems associated with
PICS. Similarly, effectively engaging and empowering
family members to be active partners in patient care early
in the course of a serious illness may lead to improved
self-care and early recognition and treatment of patients’
personal challenges. Collectively, the evidence-based
interventions that make up the ABCDEF bundle may
Mary Ann Barnes-Daly, RN, BSN, CCRN, DC, is a clinical
performance improvement consultant at Sutter Health’s Clinical
Integration Department.
Michele C. Balas, PhD, RN, APRN-NP, CCRN, FCCM, is an
associate professor at the Center of Excellence in Critical and
Complex Care, The Ohio State University College of Nursing.
Brenda T. Pun, RN, MSN, is a program clinical manager at
Vanderbilt University Medical Center.
Diane Byrum, MSN, RN, CCNS, CCRN, FCCM, is manager
of Quality Implementation Programs at the Society of Critical
Care Medicine.
E. Wesley Ely, MD, MPH, FCCM, is a professor of medicine
at Vanderbilt University School of Medicine with subspecialty
training in pulmonary and critical care medicine and the
associate director for research at the Veterans Affairs
Tennessee Valley Geriatric Research Education and Clinical
Centers.
Figure 1.
Newly Modified ABCDEF Bundle3-5
ABCDEF Bundle
Assess, prevent, and manage pain
Both SAT and SBT
Choice of analgesia and sedation
Delerium: Assess, prevent and manage
Early mobility and exercise
Family engagement and empowerment
SAT = spontaneous awakening trial; SBT = spontaneous breathing trial
A
B
C
D
E
F
Figure 2.
Interconnectedness of People, Processes and Evidence5
Successful ABCDEF Bundle Implementation
People:
ICU Patients
ICU Families
ICU Providers
Processes:
Communication
Teamwork
Rounding
Communication
Evidence:
ABCDEF Bundle
substantially reduce the incidence of PICS, allowing criti-
cally ill patients and their families to thrive after a serious
illness. For more information about the ABCDEF bundle
and ICU Liberation activities, please visit www.icudeli-
rium.org and www.iculiberation.org.
References and disclosures are available at
www.sccm.org/criticalconnections.
Learn more at www.iculiberation.org.
12. Drug shortages are becoming a common occurrence
throughout the healthcare spectrum in the United
States and affect every phase of care.1,2
Ongoing drug
shortages increased from 150 in 2010 to almost 300
in 2012 and stayed at this level throughout 2014.2
Generic injectable products, such as opiates, antibiotics,
electrolytes, heparin, and saline fluids, have been most
vulnerable.1
Furthermore, many agents, both injectable
and oral, have been withdrawn from the market; these
include phentolamine and sodium biphosphate/sodium
phosphate (Fleet Phospho-soda). Unfortunately, there are
no easy solutions, especially for patients who are allowed
nothing by mouth.
The risks of drug shortages have largely been
anecdotal, but intensive care unit (ICU) patients may be
at greatest risk. In a recent study of patients receiving
parenteral nutrition after laparotomy, Bible et al
demonstrated that patients receiving parenteral nutrition
during severe shortages required more magnesium
supplementation and had longer hospital lengths of stay
and more laboratory draws.1
Similarly, ICU patients who
are not able to take oral dosage forms may be at risk for
adverse events due to drug shortages.
Electrolytes
Electrolytes are some of the most commonly used
medications, and many ICUs use nurse-driven electrolyte
replacement protocols. For patients who are mechanically
ventilated and have small-bore feeding tubes in place,
intravenous (IV) electrolyte replacement may be preferred
for a variety of reasons, including the potential for
clogging feeding tubes. For example, administration
of sodium chloride tablets through a feeding tube is
problematic because the tablets do not crush or go into
solution easily. Because sodium chloride is readily soluble
in water, use of table salts such as salt packets may be an
alternative. Six salt packets are approximately equal to
one teaspoon or 100 mEq.3
These dissolve easily in water
and can be safely administered through enteral tubes.
With the market withdrawal of sodium biphosphate and
sodium phosphate solutions, phosphorus replacement
is also problematic, because the commercially available
tablets do not dissolve easily. Milk may be an alternative.
Eight ounces of skim milk contains 8 mmol phosphorus,
5 mEq potassium and 3 mEq sodium.3
Drug Shortages
Vasopressor-Induced Extravasation
In critically ill patients, the IV route is usually preferred
because of both rapid onset and inability to administer
medications orally. However, one of the most serious
complications of administering medications intravenously
is extravasation injury. These injuries may manifest across
a wide spectrum of symptoms, including but not limited
to pain, limitations in mobility, nerve damage, loss of
limb or limb function, and death.4
Although cytotoxic
agents are most commonly implicated, Le and Patel
discovered that during the past 50 years there have been
232 published cases of extravasation injury associated
with approximately 37 noncytotoxic agents.5
Of these,
phenytoin, parenteral nutrition, electrolytes, and
vasopressors are the most common agents or medication
classes. For a comprehensive review of the evaluation
and management of extravasation injury secondary to
noncytotoxic medications, the reader is referred to two
recently published reviews.5,6
The true incidence of vasopressor-induced
extravasation necrosis is unknown, but earlier data suggest
rates as high as 60% and 68% for norepinephrine and
dopamine, respectively.5,6
Phentolamine was the preferred
The Society of Critical Care Medicine’s Drug Shortages Committee is a multiprofessional group charged with providing resources to members to help optimally manage drug short-
ages affecting critically ill and injured patients. Committee members share their personal experiences, identify current trends in drug shortages and offer insight into various safety
and quality improvement issues. Members also provide information on the safe and consistent management of drug shortages as well as on additional resources and strategies in
regular Drug Shortage Alerts, which are accessible at www.sccm.org/currentissues.
Managing Drug Shortages in the ICU:
Thinking Outside the Box
12 | August/September 2015 +1 847 827-6869 Critical Connections
13. Critical Connections www.sccm.org August/September 2015 | 13
Stacey Folse, PharmD, MPH, BCPS, is a critical care
pharmacist at the Emory University Hospital in Atlanta,
Georgia, USA. She is a member of the Society of Critical Care
Medicine’s Drug Shortages Committee.
Anthony Gerlach, PharmD, BCPS, FCCP, FCCM, is
a surgical intensive care unit clinical pharmacist at The
Ohio State University Wexner Medical Center in Columbus,
Ohio, USA. He is a member of the Society of Critical Care
Medicine’s Drug Shortages Committee.
Farooq Bandali, PharmD, is a clinical assistant professor
at Rutgers University and critical care clinical pharmacist
at Saint Peter’s University Hospital. He is a member of the
Society of Critical Care Medicine’s Drug Shortages Committee.
Drug Mechanism of Tissue Damage Considerations Pharmacologic Treatments Alternate Treatments
Table 1.
Management of Extravasation Injuries5,6
Norepinephrine
Dopamine
Dobutamine
Epinephrine
Phenylephrine
Methylene blue
Vasopressin
Norepinephrine is thought to be the most
frequently reported vasopressor-induced
extravasation.
At high doses, dopamine possesses α1
-adrenergic
receptor activity that may lead to vasospasm.
However, there are reports of vasospasm even at
the lower end of the dose range.
Dobutamine possesses partial α agonist activity,
which at high doses may be responsible for
extravasation.
Most of the described epinephrine infiltration is
caused by inadvertent injections by autoinjector
devices.
Of the vasopressors, phenylephrine is the most
selective α1
- adrenergic receptor agonist.
Extravasation of methylene blue may cause
intense vasoconstriction.
Vasopressin exhibits smooth muscle vasoconstric-
tive effects through the V1
receptor.
Terbutaline, 1 mg in 10 mL normal saline, injected
locally across symptomatic sites.
Topical nitroglycerin, 2% 1-inch strip, applied to site
of ischemia; may redose every 8 hours as needed
Use warm compresses.
Consider elevation of extravasated extremity.
Alternate therapy for all vasopressors: topical
nitroglycerin, 2% 1-inch strip, applied to site of
ischemia; may redose every 8 hours as needed
Local ischemia secondary to vasoconstric-
tion of veins, capillaries and vasa vasorum;
altered tissue metabolism and redistribu-
tion of blood flow
agent in managing vasopressor-induced extravasation
injury, but is no longer available. Therefore, clinicians are
forced to look for alternatives. Two possible alternatives
are terbutaline and topical nitroglycerin. Data are sparse
and based on case reports. Terbutaline may be used for
extravasation injuries from norepinephrine, epinephrine,
dopamine, and dobutamine.5,6
Topical nitroglycerin is
preferred for injuries from vasopressin or methylene blue,
but may be used in all vasopressor-induced extravasation
injuries.5,6
Hyaluronidase monotherapy and ice packs
should be avoided because these therapies may not be
beneficial, and the use of ice packs may even worsen
the condition.6
Table 15,6
provides a summary of the
mechanisms of damage, pharmacologic treatments
(including doses), and alternate treatments (including
nonpharmacologic treatments).
Methemoglobinemia
Acquired methemoglobinemia is a life-threatening
complication associated with the administration of
some medications (e.g., benzocaine, dapsone, lidocaine,
metoclopramide, nitroglycerin, nitroprusside, primaquine,
and sulfonamides) commonly used in the ICU. When
oxygen delivery is impaired due to methemoglobinemia,
methylene blue is the treatment of choice.7
Currently,
methylene blue is on shortage due to manufacturing
delays. However, ascorbic acid is an alternate antidote.7-9
It acts as a strong reducing agent of the methemoglobin
molecule in vitro.9-11
Recent studies and case reports have
shown ascorbic acid to be an effective and safe treatment.
In these studies, ascorbic acid was given in different
doses and durations (1 to 2 grams IV daily for 3 to 4 days
and up to 10 grams IV over 6 hours).7,8,11-13
There is no
consensus regarding the dose and duration of ascorbic
acid therapy for methemoglobinemia. However, low doses
and a short duration of therapy can cause suboptimal
reduction in methemoglobin.10,11
The IV route of
administration is preferred, because the oral route cannot
attain high serum ascorbic acid concentrations.11-14
One
potential complication of ascorbic acid therapy is an
increase in urinary excretion of oxalate.11-14
In patients
with renal insufficiency, long-term administration of high-
dose IV ascorbic acid can cause oxalate nephropathy.6,9
Therefore, renal function should be assessed both before
and after treatment, and IV ascorbic acid should be
administered for a short duration.
Drug shortages and market withdrawal of injectable
medications continue to be problems. Clinicians may
need to think outside the box to deal with shortages.
Use of alternate and non-traditional products may be
options for critically ill patients, especially those who
cannot tolerate traditional oral dosage forms. Shortages
are best addressed at the level of each institution, through
an interdisciplinary team. Having the ICU care team
develop and communicate plans to address shortages is
essential.
References and disclosures are available at
www.sccm.org/criticalconnections.
New Publication Offers
Sedation Liberation and
Patient Mobility Strategies
Discover strategies for managing pain, agitation and
delirium in intensive care unit (ICU) patients with ICU
Liberation: The Power of Pain Control, Minimal
Sedation, and Early Mobility, a publication from the
Society of Critical Care Medicine (SCCM). Created
by a team of intensive care experts, including Michele
Balas, PhD, RN, APRN-NP, CCRN, FCCM; Terry
Clemmer, MD, FCCM; and Ken Hargett, MHA, RRT,
FAARC, FCCM, this must-have publication offers
practical information to help frontline staff implement
sedation liberation and promote ICU patient mobility.
Topics include:
• Gap analysis in performance improvement
• Delirium in the ICU
• Patients’ need for sleep
• Ventilator strategies
Chapters provide evidence based on expert opinion,
principles derived from other disciplines and practical
experience.
ICU Liberation: The Power of Pain Control, Minimal
Sedation, and Early Mobility is available for purchase
in the SCCM Store in print and as an eBook for $75
for members ($95 for nonmembers). If you have any
questions, please contact SCCM Customer Service
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14. 14 | August/September 2015 +1 847 827-6869 Critical Connections
Ultrasonography has come a long way as a medical
diagnostic tool since its inception in the 1950s. With the
development of real-time ultrasonography in the 1980s
and advances in portability, cost effectiveness, and fast
diagnostics, it has grown to become an essential tool for
physicians and advanced care practitioners who treat
critically ill patients.1
Studies have revealed the use of emergency bedside
ultrasonography in a wide spectrum of situations, such as
procedure guidance,2
determination of cardiac activity,3
evaluation of pericardial effusion4
and assessing fluid
responsiveness and hypotension,5
deep vein thrombosis,6
thoracoabdominal trauma,7
and ectopic pregnancy.8
Useful information can be obtained even from air-
containing organs such as lungs, which do not conduct
ultrasound waves.9
With the increased safety and success
of direct visual guidance of bedside diagnostic or thera-
peutic procedures, ultrasound guidance (i.e., placement
of central venous catheters) has been recommended as
the standard of care.10
Bedside critical care ultrasonography differs in impor-
tant ways from the traditional ultrasonography performed
by radiologists or echocardiography performed by cardi-
ologists.1
Its use starts with a specific question in a rapidly
deteriorating patient that requires immediate interpre-
tation and clinical decision-making. Repeated bedside
ultrasonography is then performed to assess the changing
status and to modulate treatment accordingly.
The biggest limiting factor to bedside critical care ultra-
sonography is that the quality and interpretation of the
images are operator dependent. Sonographers, radiolo-
gists and cardiologists are certified and credentialed in
their fields. Certification for bedside critical care ultra-
sonography is still emerging. To date, there is no critical
care ultrasonography certification approved or provided
by a member board of the American Board of Medical
Specialties (ABMS).
In 1991, both the American College of Emergency
Physicians (ACEP) and the Society for Academic
Emergency Medicine (SAEM) published position papers
recognizing the utility of ultrasonography for patients in
emergency situations.11,12
In the mid-1990s, SAEM13
and
the American College of Surgeons (ACS) developed edu-
cational curricula to standardize bedside ultrasonography
training.14
In 1997, the ACS Board of Regents published
a statement regarding verification of a surgeon’s ultraso-
nography qualifications.15
In 2001, ACEP published the
Emergency Ultrasound Guidelines, which were revised in
2008.16
These guidelines pertain to the scope of practice
and clinical indications for emergency ultrasonography.
In 2007, Critical Care Medicine published supplements
that defined critical care ultrasonography and advanced
critical care echocardiography (CCE).17,18
In 2009, the
American College of Chest Physicians (CHEST) and the
Société de Réanimation de Langue Française published
their competency statement on critical care ultrasonog-
raphy. This statement divided applications into general
critical care ultrasound (GCCUS), basic critical care
echocardiography and advanced critical care echocar-
diography.19
In 2011, representatives of 12 critical care
societies worldwide worked on a framework for organiz-
ing training targeted at GCCUS and basic and advanced
CCE. They recommended that GCCUS and basic CCE
training should be mandatory in the curriculum of
intensive care unit providers, and each critical care society
should support this training in its own country.20
The Society of Critical Care Medicine’s (SCCM’s) offi-
cial statement provides recommendations for achieving
and maintaining competence and credentialing in critical
care ultrasonography with focused cardiac ultrasonog-
raphy and advanced CCE.21
It suggests that this can be
achieved by either a fellowship-based pathway (for those
in fellowship training) or a practice-based experience
pathway (for practicing providers). However, a Web-based
2010 survey of program directors of American pulmo-
nary critical care and critical care fellowship programs
identified several barriers to critical care ultrasonography
training in fellowship programs, including fellow turnover,
insufficient faculty training, and perceived length of time
required for echocardiography training.22
Nevertheless,
if this training is not captured in fellowship, there is less
opportunity to receive it post-fellowship. A study of prac-
ticing emergency physicians in 2012 showed that physi-
cians who completed training before 2001 were less likely
to be credentialed than those trained after 2001. “Lacking
hands-on experience” and “being too busy” were cited as
the most common barriers to their credentialing.23
Currently, there is no widely accepted standard
regarding need for certification for ultrasound or how
to obtain certification if desired. In the future, there
In-Training
The Role of Critical Care Specialty Societies
in the Certification and Credentialing of
Bedside Ultrasonography
The Society of Critical Care Medicine’s (SCCM) In-Training Section is dedicated to assisting and guiding trainees as they progress through training
into independent practice. It also aims to foster career development following this transition. To further this mission, members contribute articles
addressing emerging issues in critical care training and career development; these submissions are authored by in-training professionals under
the guidance of a mentor. For additional information about the In-Training Section or this project, please contact Section Chair Utpal Bhalala, MD,
Chair-elect Ashish Khanna, MD, FCCP, or Member-at-Large Erik Vakil, MD.
may be a requirement for certification that is linked to
billing authority, especially with lobbying pressure from
radiology or cardiology, but currently certification is not
standard or offered by any specialty society or ABMS
board. Organizations such as World Interactive Network
Focused on Critical Ultrasound (WINFOCUS) are pro-
viding avenues for training in point-of-care ultrasonogra-
phy around the world.24
Societies such as SCCM and the
American Thoracic Society provide training workshops
at their annual meetings.25,26
SCCM has created online
modules that allow providers to practice their skills from
the convenience of their homes and at their own pace to
earn continuing medical education credit (Self-Directed
Critical Care Ultrasound).27
SCCM is now also offering
critical care ultrasonography courses internationally.
Critical care societies are playing a crucial role in
providing standardized training modules in critical care
ultrasonography, which could facilitate hospitals’ cre-
dentialing pathways for trainees and practicing critical
care providers. As ultrasonography becomes ubiquitous
and accepted as a standard of care, consensus regarding
this training should occur across disciplines to maintain
quality. More opportunities are needed for providers out
of training to learn these new skills in a convenient, cost-
effective way without compromising the integrity of the
certification and credentialing process.
References and disclosures are available at
www.sccm.org/criticalconnections.
Chaitanya Mandapakala, MD, is a fellow in the Division of
Pulmonary Critical Care and Sleep Medicine at Wayne State
University in Detroit, Michigan, USA.
Sarah Lee, MD, MPH, is an assistant professor in the
Division of Pulmonary Critical Care and Sleep Medicine at
Wayne State University in Detroit, Michigan, USA. She is a
Member-at-Large of the Society of Critical Care Medicine’s
In-Training Section.
15. Whether you missed the 2015 Critical Care Congress in Phoenix, Arizona, USA, or couldn’t make it to all the
sessions of interest, you can experience the educational content from the most popular sessions online at your
convenience. Earn free CME credits by viewing any of the following webcasts and then applying for credit.
Earn Free CME!
Enduring materials offering Continuing Medical Education credits from
SCCM’s 44th Critical Care Congress are available at www.sccm.org/enduringmaterials.
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16. 16 | August/September 2015 +1 847 827-6869 Critical Connections
As of October 1, 2015, all codes for medical diagnosis
and inpatient procedures for patients covered by the
Health Insurance Portability and Accountability Act were
required to transition from International Classification of
Diseases (ICD)-9 codes to ICD-10. This change resulted
in considerable modification to coding and billing
procedures.
Background
ICD-10, published by the World Health Organization,
has two purposes in the United States. The Centers for
Medicare Medicaid Services (CMS) developed the
ICD-10 Clinical Modification (ICD-10-CM) to use in
classification of a diagnosis and reasons for visits in all
U.S. healthcare settings. It also developed the ICD-10
Procedure Coding System for procedural coding of hos-
pital inpatient care. However, providers will continue to
use Current Procedural Terminology (CPT) codes. This
article concerns only ICD-10-CM (referred to as ICD-10
in this article).
Differences Between ICD-9 and ICD-10
ICD-10 significantly increases the number of codes:
ICD-9 has approximately 14,000 codes, whereas ICD-10
increases that number to approximately 69,000 (Table 1).
These additional codes allow clinical providers to better
capture specificity in disease states. For example, in a
diagnosis of acute respiratory failure, ICD-10 adds digits
to the right of the decimal (Table 2). ICD-10 also allows
the use of holder (X) spaces to allow for future expansion.
The decision to increase the quantity of characters in a
single code allows for a more succinct description of a
particular disease and adds in codes for laterality (the side
of the body in which the disease manifests). More than
40% of ICD-10 codes designate the patient’s right or left
side. The range of severity parameters also is broader in
ICD-10, as compared to ICD-9.
In addition to the increase in specificity, ICD-10 contains
codes that combine common conditions. For example,
ICD-10 code I25.110 applies to the combination of
atherosclerotic heart disease of native coronary artery with
unstable angina pectoris, a condition that would require
two ICD-9 codes to describe. ICD-9 codes allowed the use
of only three to five characters, whereas ICD-10 expands
that number to seven characters (Figure 1).
While the number of characters might seem daunting,
a further examination of the new codes shows that most
have no effect on clinical practice. Of the 69,000 codes,
approximately 40,000 deal with symptoms associated
with injury, poisoning and other external causes, while
another 8,000 deal with morbidity reporting or health
status.1
Those 48,000 codes are not commonly used in
clinical practice.
This leaves approximately 21,000 ICD-10 codes useful
for clinical practice, an approximately 50% increase over
the ICD-9 codes. The number of new codes used varies
widely by the type of practice. For instance, ICD-10 pro-
Coding Corner
Introducing
ICD-10
vides for greater specificity in orthopedic codes and adds
designations for laterality, so practices with a significant
orthopedics component have seen significant changes.
By contrast, a typical medical intensive care unit practice
sees more codes to increase specificity in pneumonia and
diabetes, for example, but not much else.
Let us look at one instance where the number of codes
has marginally increased. ICD-9 had four codes for acute
respiratory failure, three of which took into account
certain modifications, such as acute respiratory failure
following trauma and surgery (Table 2). With ICD-10,
additional modifiers for hypercapnia and hypoxia double
the number of codes to eight—still only an increase of
four in that particular diagnosis.
ICD-9 ICD-10
Table 1.
Differences Between ICD-9 and ICD-10
No laterality
3-5 digits
No placeholder
characters
14,000 codes
Limited severity
parameters
Limited
combination codes
Laterality – Right or left account for 40%
of codes
7 digits
“X” placeholders
69,000 codes to better capture specificity
Extensive severity parameters
Extensive combination codes to better
capture complexity
Source: Centers for Medicare Medicaid Services. Road to 10: http://www.roadto10.org/whats-different/
ICD-9 CODE ICD-9 CODE DESCRIPTION ICD-10 CODE ICD-10 CODE DESCRIPTION
Table 2.
Comparison of ICD-9 and ICD-10 Codes for Acute Respiratory Failure
518.51
518.53
518.81
518.84
Acute respiratory failure following trauma
and surgery
Acute and chronic respiratory failure
following trauma and surgery
Acute respiratory failure
Acute and chronic respiratory failure
J95.821
J95.822
J96.00
J96.01
J96.02
J96.20
J96.21
J96.22
Acute postprocedural respiratory failure
Acute and chronic postprocedural
respiratory failure
Acute respiratory failure, unspecified
whether with hypoxia or hypercapnia
Acute respiratory failure with hypoxia
Acute respiratory failure with hypercapnia
Acute and chronic respiratory failure,
unspecified whether with hypoxia or
hypercapnia
Acute and chronic respiratory failure with
hypoxia
Acute and chronic respiratory failure with
hypercapnia
Source: American Academy of Professional Coders. ICD-10 code translator: https://www.aapc.com/icd-10/codes/. Copyright (c) AAPC.
17. Critical Connections www.sccm.org August/September 2015 | 17
David L. Carpenter, MPAS, PA-C, is a physician assistant
in the Surgical/Transplant ICU at the Emory Center for Critical
Care in Atlanta, Georgia, USA. He is the Chair of the Society of
Critical Care Medicine’s Coding and Billing Committee.
Transition to ICD-10
It is beyond the scope of this article to describe the com-
plete transition to ICD-10. Generally speaking, organiza-
tions should have taken steps to ensure that all elements
of their billing cycle comply with ICD-10. These ele-
ments include billing software, the billing staff, practice
management, and electronic health record vendors. In
addition, all organizations must retain close communica-
tion with payers to ensure compliant submission of claims
in the wake of this transition.
Provider Education
While billing workflow varies, providers and coders have
changed, or must change, their methods as a result of this
transition. This means staff education is key. To ensure
accurate coding, those involved must understand the
increased specificity and the addition of laterality. In cod-
ing and billing, the translation from one code to another
is known as “crosswalk.” One common method used to
educate providers about the new codes is giving concrete
examples by “crosswalking” the top 50 ICD-9 codes over
to the ICD-10 counterparts.
Fortunately, a white paper by athenahealth2
indicates
that 73.3% of ICD-10 codes are an approximate or
exact match to those in ICD-9, and another 18.7% have
one match with multiple choices. Generally speaking,
the other 8% either have no mapping at all or require
complex mapping. So 92% of the new codes should be
relatively easily to crosswalk.
A number of firms provide commercial applications for
crosswalking. For organizations with database capability,
CMS publishes General Equivalence Mappings (GEMs),
which show crosswalks for 2015 ICD-10 codes.3
Another
resource is provided by the American Academy of
Professional Coders (AAPC), which has an online ICD-9
Additional Resource
Centers for Medicare Medicaid Services.
ICD-10 Resource Center.
www.cms.gov/Medicare/coding/ICD10
Figure 1.
ICD-10 Code Structure
Source: Centers for Medicare Medicaid Services. ICD-10 Basics. http://www.roadto10.org/icd-10-basics/.
ALPHA
(NOT U) NUMERIC
CATEGORY
CHACTERS 3-7 CAN BE ANY COMBINATION OF ALPHA OR NUMERIC
ETIOLOGY, ANATOMICAL SITE, SEVERITY EXTENSION
1st
DIGIT
2nd
DIGIT
3rd
DIGIT
4th
DIGIT
5th
DIGIT
6th
DIGIT
7th
DIGIT
IntensIvIsts
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to ICD-10 translator tool (https://www.aapc.com/icd-
10/codes/). Finally, CMS has an ICD-10 lookup tool
(http://www.cms.gov/medicare-coverage-database/stat-
icpages/icd-10-code-lookup.aspx).
These aids help to crosswalk commonly used codes
and consequently generate updated sets. Organizations
that use superbills can convert these in a similar man-
ner. After crosswalking superbill codes, the provider can
produce a claim that is compliant with ICD-10.
Conclusion
This significant change to the billing cycle involved
multiple intermeshed agencies. As such, the introduc-
tion of ICD-10 has initially created significant strain
on healthcare organizations. Ensuring that all billing
elements comply with ICD-10 is vital to ensure proper
documentation.
References and disclosures are available at
www.sccm.org/criticalconnections.
SCCM Announces THRIVE Peer Support Collaborative Grant Awardees
Millions of patients each year survive a serious or life-threatening illness only to face an often painful and challenging course of
recovery. In an effort to assist patients after an intensive care unit (ICU) discharge, the Society of Critical Care Medicine (SCCM)
launched the THRIVE Initiative. A key component of this initiative is the newly minted THRIVE Peer Support Collaborative, which
has SCCM partnering with six inaugural sites to foster a network of in-person support groups linking survivors of critical illness
and their families. SCCM would like to formally congratulate all six grant awardee sites.
The Collaborative, which will grow in subsequent years as additional sites are invited to participate, will enable the creation of
face-to-face groups in which survivors offer each other mutual support and share solutions related to ICU recovery.
• Dell Children’s Medical Center of Central Texas —
Austin, Texas, USA
• University of Washington/Harborview Medical Center —
Seattle, Washington, USA
• UC San Diego Medical Center — La Jolla, California, USA
• Brigham and Women’s Hospital — Boston, Massachusetts, USA
• NorthShore University HealthSystem — Evanston, Illinois, USA
• Vanderbilt University Medical Center — Nashville, Tennessee, USA
![Everything is at least 2-3 times worse with
Moderate to Severe AKI
50% of patients in the ICU will develop
some stage of Acute Kidney Injury (AKI)
LOS
Hospital
Cost
30-Day
Readmission
Hospital
Mortality
16 days
11 days
5 days
28.6%
21.8%
9.3%
$52,600
$38,900
$18,500
1x
2x - 3x
Greater
5x - 11x
Greater
2x 3x
2x 4x 6x 8x 10x 12x
26.0%
12.9%
2.3%
Short-term & long-term consequences
associated with increasing AKI severity
LOS3
: Total postoperative length of stay (days/patient);
Hospital Cost3
: Total postoperative cost (US$/patient); 30-Day
Readmissions4
: Percent of postoperative patients; Hospital
Mortality3
: Percent of postoperative patients.
No AKI Moderate Severe
[1] McCullough P, et. al. Contrib Nephrol. 2013;182:13-29.
[2] Mandelbaum T, et. al. Crit Care Med. 2011;39(12):2659-2664
Acute Kidney Injury is an increasingly common and potentially devastating complication in hospitalized individuals.1
Studies suggest
that approximately half of all patients admitted to the ICU will develop some stage of Acute Kidney Injury.2
If a patient develops an AKI
complication during hospitalization, short-term and long-term consequences could be twice as severe, such as length of stay (LOS),3
hospital
cost,3
30-day readmissions4
and hospital mortality.3
[3] Dasta J, et. al. Nephrol Dial Transplant. 2008;97(1):1970- 1974
[4] Brown J, et. al. Ann Thorac Surg. 2014;97(1):111-117
[5] Martensson J, et al. Brit J Anaesth. 2012;109(6):843-50.
The NephroCheCk®®
® Test System is intended to be used in conjunction with clinical evaluation in patients who currently have or have had
within the past 24 hours acute cardiovascular and or respiratory compromise and are ICU patients as an aid in the risk assessment for
moderate or severe acute kidney injury (AKI) within 12 hours of patient assessment. The NephroCheCk®®
®®
® Test System is intended to be used
in patients 21 years of age or older.
Intended Use and Indications for the NephroCheCk�
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A quantitative AKIRISKª
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to discriminate patients at risk of AKI.
Identify:
Clinicians can triage patients
into lower risk and greater risk
groups for developing moderate to severe
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Acute Kidney Injury.
Mitigate:
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acute kidney injury (AKI)
The NephroCheCk®®
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proactively assess the need for AKI preventative measures.
Astute Medical, Inc.
Phone: +1 (855) 317-2788
(M—F, 8am to 5pm PST)
customerservice@astutemedical.com
technicalsupport@astutemedical.com
To implement the
NephroCheCk®
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please ask your local
Ortho Clinical Representative
or contact:
The NephroCheCk®
Test: A Renal “Alarm System”
The NephroCheCk®®
®® Test quantitatively measures two urinary biomarkers - tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth
factor binding protein 7 (IGFBP-7) - and combines them into a single AKIRISKª Score. Both biomarkers are thought to be involved in G1
cell-cycle arrest during the earliest phases of injury to the kidney.6
[6] Kashani K, et. al. Crit Care. 2013;17:R25
�2015 Astute Medical, Inc. Astute Medical®, the AM logo, Astute140®, NephroCheCk�®
and the NephroCheCk�®
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trademark of Astute Medical, Inc. For information regarding trademarks and other intellectual property applicable to this product, including international trademarks, please see AstuteMedical.com/US/
About/IntellectualProperty. PN 0459 Rev B 2015/07/28.
The challenge is that acute kidney injury (AKI) is difficult to identify early1
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