Objective Delirium, an acute organ dysfunction, is common among critically ill patients leading to significant morbidity and mortality; its epidemiology in a mixed cardiology and cardiac surgery intensive care unit (CVICU) is not well established. We sought to determine the prevalence and risk factors for delirium among CVICU patients. Design Prospective observational study. Setting 27-bed medical-surgical CVICU. Patients 200 consecutive patients with an expected CVICU length of stay >24 hours. Interventions None. Measurements Baseline demographic data and daily assessments for delirium using the validated and reliable Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were recorded, and quantitative tracking of delirium risk factors were conducted. Separate analyses studied the role of admission risk factors for occurrence of delirium during the CVICU stay and identified daily occurring risk factors for the development of delirium on a subsequent CVICU day. Main Results Prevalence of delirium was 26%, similar among cardiology and cardiac surgical patients. Nearly all (92%) exhibited the hypoactive subtype of delirium. Benzodiazepine use on admission was independently predictive of a 3-fold increased risk of delirium [Odds Ratio 3.1 (1, 9.4), p=0.04] during the CVICU stay. Of the daily occurring risk factors, patients who received benzodiazepines [2.6 (1.2, 5.7), p=0.02] or had restraints or devices that precluded mobilization [2.9 (1.3, 6.5), p<0.01] were more likely to have delirium the following day. Hemodynamic status was not associated with delirium. Conclusions Delirium occurred in 1 in 4 patients in the CVICU and was predominately hypoactive in subtype. Chemical restraints via use of benzodiazepines or the use of physical restraints/restraining devices predisposed patients to a greater risk of delirium, pointing to areas of quality improvement that would be new to the vast majority of CVICUs.

Immediate bedside availability of ultrasound resources can dramatically improve the ability of critical care physicians to care for critically ill patients. Anesthesia--critical care medicine training should have definitive expectations and performance standards for basic CCUS interpretation by anesthesiology--critical care specialists. The learning goals in this review reflect current trends in the multispecialty critical care environment where ultrasound-based diagnostic strategies are already frequently applied. These competencies should be formally taught as part of an established anesthesiology-critical care medicine graduate medical education programs.

Background Although a single dose of etomidate can cause relative adrenal insufficiency the impact of etomidate exposure on postoperative outcomes is not known. The objective of this study was to examine the association between a single induction dose of etomidate and clinically important postoperative outcomes following cardiac surgery. Methods We retrospectively examined the association between etomidate exposure during anesthetic induction and postoperative outcomes in patients undergoing cardiac surgery from January 2007 to December 2009 using multivariate logistic regression analyses and Cox proportional hazards regression analyses. Postoperative outcomes of interest were severe hypotension, mechanical ventilation hours, hospital length of stay and in-hospital mortality. Results Sixty-two percent of 3,127 patients received etomidate. Etomidate recipients had a higher incidence of preoperative congestive heart failure (23.0% vs. 18.3%, p = 0.002) and a lower incidence of preoperative cardiogenic shock (1.3% vs. 4.0%, p < 0.001). The adjusted odds ratio for severe hypotension and in-hospital mortality associated with receiving etomidate was 0.80 (95% CI: 0.58 to 1.09) and 0.75 (95% CI: 0.45 to 1.24) respectively, and the adjusted hazard ratio for time to mechanical ventilation removal and time to hospital discharge were 1.10 (95% CI: 1.00 to 1.21) and 1.07 (95% CI: 0.97 to 1.18) respectively. Propensity score analysis did not change the association between etomidate use and postoperative outcomes. Conclusions In this study, there was no evidence to suggest that etomidate exposure was associated with severe hypotension, longer mechanical ventilation hours, longer length of hospital stay or in-hospital mortality. Etomidate should remain an option for anesthetic induction in cardiac surgery patients.

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A simulated transesophageal examination of normal cardiac anatomy in concert with a standardized assessment tool permits ample discrimination between expert and novice echocardiographers as defined for this investigation. Future research will examine in detail the role echocardiography simulators should play during echocardiography training including assessment of training level.