In patients with combined discrete coarctation and significant hypoplasia of the distal arch order chloramphenicol no prescription antimicrobial underwear, this technique can be combined with a standard coarctectomy cheap chloramphenicol online master card bacteria joe. The distal arch must be mobilized order discount chloramphenicol line antibiotic resistance youtube, as well as the origin of the left carotid artery and the portion of the arch just proximal to it. The transected subclavian artery is opened medially onto the aortic arch, across the roof of the distal arch, and onto the base of the left carotid artery. In these cases, extended resection with an anastomosis of the distal aorta to the undersurface of the aortic arch should be carried out. Extensive dissection and mobilization of the aorta from the origin of the innominate artery to the descending thoracic aorta at the level of the third or even fourth intercostal artery are carried out. A curved vascular clamp is placed across the origin of the left subclavian and left carotid arteries as well as the proximal aortic arch just beyond the innominate artery. An incision is now made inferiorly on the aortic arch while a second matching incision is made on the lateral aspect of the distal aorta. The descending aorta is then anastomosed to the opening in the aortic arch with a running suture Prolene. Monitoring the pressure in a right radial arterial line will allow this problem to be detected and quickly rectified. Tension at the Anastomosis Aggressive proximal and distal mobilization will avoid tension on the anastomosis; this will minimize the risk of suture line bleeding and the subsequent development of stenosis. Division of Intercostal Vessels It may be necessary to ligate and divide one set of intercostal arteries in order to adequately mobilize the descending aorta for a tension-free anastomosis. Balloon angioplasty is also an alternative to surgery for native coarctations in patients older than 3 months of age who have a discrete aortic narrowing. Extraanatomic bypass grafts, such as those between the left subclavian and descending aorta or from the ascending to the descending aorta, are rarely used now. Even the most complex recoarctations can be dealt with directly using excision and an interposition graft or patching of the narrowed segment. If a left thoracotomy approach is deemed to be inadvisable, a median sternotomy with the use of cardiopulmonary bypass and deep hypothermia allows good exposure of the distal arch and proximal descending aorta (see Chapter 8). These include patients with multiple muscular ventriculoseptal defects or ventriculoseptal defects complicated by other noncardiac congenital anomalies. Patients who present after 4 to 6 weeks of age with simple transposition of the great arteries may require preliminary pulmonary artery banding to prepare the left ventricle for an arterial switch procedure (see Chapter 25). Banding of the pulmonary artery is also performed in some patients with univentricular hearts and pulmonary overcirculation (see Chapter 30). A left thoracotomy incision is used in some patients, especially if the banding is performed in conjunction with the repair of a coarctation. The main pulmonary artery is dissected free from the aorta and the origin of the right pulmonary artery is identified. A band of Silastic 3- to 4-mm wide is placed around the proximal pulmonary artery and tightened until the pressure distal to the band is approximately one-third systemic with an arterial oxygen saturation no less than 75% on 50% inspired oxygen. The constriction site on the band is made permanent with stainless steel clips or interrupted sutures. The band is then secured to the adventitia of the pulmonary artery at various intervals with interrupted 6-0 or 5-0 Prolene sutures. The main pulmonary artery is isolated, and the Silastic band is passed around it and narrowed as described previously. Regular suture material or a narrow band may cut through and produce hemorrhage that is difficult to control. Difficulty Passing the Band around the Pulmonary Artery It may be easier and safer to initially pass the tape around both the aorta and pulmonary artery through the transverse sinus and then between the aorta and pulmonary artery. Troublesome Bleeding Small adventitial vessels on the aorta and pulmonary artery may give rise to troublesome bleeding; they must be identified and cauterized. Excessive Banding the degree of banding must not be too constrictive because this will result in unacceptable cyanosis and possible hemodynamic collapse. Inadequate Banding Many times, the tightness of the band is limited by the hemodynamic response of the patient. To limit the pulmonary blood flow in these patients, ligation of the pulmonary artery or a Damus-Kaye-Stansel anastomosis and shunt procedure may be required (see Chapter 30). Early Reoperation to Adjust Band It is not uncommon to leave the operating room with a suitable band, only to have the patient develop signs that the band is too tight or too loose in the early postoperative period. Placing the Band Too Proximally If the band is placed too proximally, the sinotubular ridge of the pulmonic valve will be distorted. To adequately relieve the gradient during the debanding procedure, the sinus portion(s) of the pulmonary root often needs to be patched. This is especially problematic when an arterial switch or Damus-Kaye-Stansel procedure is planned at the second stage. Band Migration the band should be sewn to the adventitia of the proximal aspect of the main pulmonary artery. This precaution prevents the band from migrating distally, narrowing the pulmonary artery at its bifurcation and obstructing the right, left, or both branches. After the optimal band constriction has been achieved, it is secured and the pericardium is approximated with multiple interrupted sutures. A punch is taken from the center of this disc, whose diameter is roughly the size of a shunt appropriate for the baby by weight. A transverse, partial pulmonary arteriotomy is made halfway between the pulmonary root and the bifurcation, and through this partial incision, the backwall of the Gore-Tex “washer” is sewn using a running Prolene. As this is continued anteriorly, the Gore-Tex is included in between the two edges of the cut pulmonary artery. This technique has the advantage of (1) a controlled source of pulmonary blood flow and (2) eliminating the possibility of either band migration or pulmonary valve damage. This device is capable of repeated narrowing and releasing of the pulmonary artery at the bedside, avoiding reoperation. Because of its elliptic shape, there usually is no need for reconstruction of the pulmonary artery when the device is removed. It may be necessary to reconstruct the pulmonary artery to eliminate any gradient across the band site. When a Silastic band has been in place for a short time, simple removal of the band often results in no gradient. If a pressure gradient or obvious deformity is noted at the band site, the pulmonary artery is repaired with the patient on cardiopulmonary bypass. An appropriately sized patch of glutaraldehyde-treated autologous pericardium or Gore-Tex is then sewn onto the defect with a continuous 5-0 or 6-0 Prolene suture. Persistence of the Gradient Inadequate enlargement of the main pulmonary artery may be responsible for persistence of the gradient across the site of the band. Alternatively, the portion of the main pulmonary artery involved in the banding can be resected and an end-to- end anastomosis performed between the proximal main pulmonary artery and the confluence of the right and left pulmonary arteries. Pulmonary Valve Insufficiency When the band has caused distortion of the sinotubular ridge, patching anteriorly into one sinus only often causes valvular insufficiency. If the patient will not tolerate pulmonary valve incompetence, the pulmonary artery can be transected and all three sinuses patched as described for supravalvular aortic stenosis (see Chapter 24). Incorporation of the Band into the Pulmonary Artery With the passage of time, the band may burrow through the wall of the pulmonary artery to become subendothelial.
Surgical intervention buy chloramphenicol 500 mg fast delivery antibiotics for uti cats, either segmental or subtotal colectomy buy chloramphenicol now antibiotics and drinking, is required in 18% to 25% of patients requiring blood transfusion  purchase 500 mg chloramphenicol visa bacteria zebra. Angiotherapy with vasopressin infusion or embolization after superselective cannulation of the bleeding vessel is an alternative approach in patients unstable for surgery. There is limited evidence that endoscopic therapy can prevent recurrent bleeding and the need for surgery . Alternatively, in patients who have stopped bleeding, elective colonoscopy can be performed during the same hospital stay, after adequate bowel preparation. Aortoenteric Fistula the key to recognizing an aortoenteric fistula is inclusion within the differential diagnosis of every patient with bleeding and a history of aortic graft surgery. Although fistulas can occur rarely between a native aortic aneurysm and the intestinal lumen, they more commonly occur in patients who have undergone abdominal aortic graft surgery (0. The point of intestinal breach can be anywhere from the esophagus to the colon, but occurs most often in the third part of the duodenum (75%). The interval between the first event and the exsanguinating hemorrhage can be hours, weeks, or months (average, 1 to 3 weeks). Making the diagnosis is difficult, but upper endoscopy is useful in excluding the diagnosis by identifying another lesion that is actively bleeding or has stigmata of recent bleeding. In some cases, computed tomography of the abdomen can identify graft abnormalities such as air– fluid levels that may indicate an enteric communication . If available, a vascular surgeon and an interventional radiologist should be part of the evaluating team. Graft repair surgery or an endovascular approach may be required for a confirmed diagnosis, and exploratory surgery is likely necessary for a presumed diagnosis of a fistulized or infected graft site. Hermansson M, Ekedahl A, Ranstam J, et al: Decreasing incidence of peptic ulcer complications after the introduction of the proton pump inhibitors, a study of the Swedish population from 1974–2002. Higham J: Recent trends in admissions and mortality due to peptic ulcer in England: increasing frequency of haemorrhage among older subjects. Crooks C, Card T, West J: Reductions in 28-day mortality following hospital admission for upper gastrointestinal hemorrhage. Villanueva C, Colomo A, Bosch A, et al: Transfusion strategies for acute upper gastrointestinal bleeding. Carbonell N, Pauwels A, Serfaty L, et al: Erythromycin infusion prior to endoscopy for acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Lin H-J, Wang K, Perng C-L, et al: Early or delayed endoscopy for patients with peptic ulcer bleeding. Lin H-J, Lo W-C, Lee F-Y, et al: A prospective randomized comparative trial showing that omeprazole prevents rebleeding in patients with bleeding peptic ulcer after successful endoscopic therapy. Laine L: Systematic review of endoscopic therapy for ulcers with clots: can a meta-analysis be misleading? Vergara M, Bennett C, Calvet X, et al: Epinephrine injection versus epinephrine injection and a second endoscopic method in high-risk bleeding ulcers. Calvet X, Vergara M, Brullet E, et al: Addition of a second endoscopic treatment following epinephrine injection improves outcome in high- risk bleeding ulcers. Ljungdahl M, Eriksson L-G, Nyman R, et al: Arterial embolisation in management of massive bleeding from gastric and duodenal ulcers. Ripoll C, Bañares R, Beceiro I, et al: Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure. Hirata M, Ishihama S, Sanjo K, et al: Study of new prognostic factors of esophageal variceal rupture by use of image processing with a video endoscope. Avgerinos A, Armonis A, Raptis S: Somatostatin and octreotide in the management of acute variceal hemorrhage. Bildozola M: Efficacy of octreotide and sclerotherapy in the treatment of acute variceal bleeding in cirrhotic patients: a prospective, multicentric, and randomized clinical trial. Hwang S-J, Lin H-C, Chang C-F, et al: A randomized controlled trial comparing octreotide and vasopressin in the control of acute esophageal variceal bleeding. Besson I, Ingrand P, Person B, et al: Sclerotherapy with or without octreotide for acute variceal bleeding. Goulis J, Armonis A, Patch D, et al: Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Soares-Weiser K, Brezis M, Tur-Kaspa R, et al: Antibiotic prophylaxis for cirrhotic patients with gastrointestinal bleeding. Masci E, Stigliano R, Mariani A, et al: Prospective multicenter randomized trial comparing banding ligation with sclerotherapy of esophageal varices. Lo G-H, Lai K-H, Cheng J-S, et al: the effects of endoscopic variceal ligation and propranolol on portal hypertensive gastropathy: a prospective, controlled trial. Tan P-C, Hou M-C, Lin H-C, et al: A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-Butyl-2- Cyanoacrylate injection versus band ligation. Paquet K-J, Feussner H: Endoscopic sclerosis and esophageal balloon tamponade in acute hemorrhage from esophagogastric varices: a prospective controlled randomized trial. Laine L, Shah A, Bemanian S: Intragastric pH with oral vs intravenous bolus plus infusion proton-pump inhibitor therapy in patients with bleeding ulcers. Sachar H, Vaidya K, Laine L: Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. Nikolaidis N, Zezos P, Giouleme O, et al: Endoscopic band ligation of dieulafoy-like lesions in the upper gastrointestinal tract. In fact, descriptions of acute ulcerations of the intestines in the setting of acute burns date back more than 150 years . Management has largely focused on prevention of erosive disease through acid suppression, although this has been the subject of recent controversy because the risks of the medicines themselves must be balanced with their beneficial effects. A pooled analysis of studies performed between 1980 and 1998 revealed an incidence of 17%, whereas a similar analysis done for studies published between 1993 and 2010 showed an incidence less than 1% . In absolute numbers, mortality rates can be as high as 45% to 55% for patients with clinically significant bleeding [12,14]. However, this relationship loses significance when controlled for comorbid medical conditions and other intercurrent factors. This suggests that bleeding is more a barometer of severity of critical illness rather than a direct contributor to death [12,14]. Respiratory failure (need for mechanical ventilation >48 hours) and coagulopathy (platelet count <50,000/µL, international normalized ratio >1. Gastric epithelial cells secrete a thick mucus layer that acts as physical barrier against stomach acid and the enzyme pepsin. In addition, bicarbonate ions diffusing across the mucosa and trapped in the mucus layer act as a chemical barrier buffering acidic gastric contents [11,13]. Finally, any injury that does occur is rapidly repaired by moving new epithelial cells through the gastric unit to the mucosal surface of injury, an energy- intensive process [1,13]. Gastric regulatory factors control these processes, of which the most important are prostaglandins . This results in gastric mucosal hypoxia, with a decrease in prostaglandin production and an increase in nitric oxide and free oxygen radicals in the mucosa. Nitric oxide leads to vasodilation, with resultant mucosal hyperemia and reperfusion injury, whereas free oxygen radicals are directly toxic to cells. In the setting of hypoxia, the mucous bicarbonate barrier breaks down, exposing the gastric epithelium to damage from back diffusion of hydrogen ions as well as direct injury from the protease pepsin.
Organ failure is a cardinal feature that often involves the kidneys buy generic chloramphenicol 500 mg line infection quality control staff in a sterilization, brain order 500mg chloramphenicol with visa antibiotic lock protocol, heart buy discount chloramphenicol online bacteria breath test, lungs, and circulatory and hematologic systems. Development of each new organ failure, renal failure, and the need for inotropic support is associated with increased mortality . Identification of the precipitating event, directed treatment, prevention of further injury, and supportive care is the standard approach. Liver support devices have attracted much publicity as a possible treatment option for these patients. A study of the Prometheus device showed that it was well tolerated and successful at decreasing serum bilirubin level, but with unchanged survival at 28 and 90 days when compared to those who did not undergo this therapy . A patient with acute decompensated Wilson disease is also granted status 1A as a result of poor survival without a liver transplant. Selection also must discriminate the appropriate patient who would die without a transplant from the patient who is too sick for transplant and the patient who would likely recover only with supportive care. Psychosocial factors are likewise important for determining eligibility and are necessary components of transplant evaluation. Medical contraindications to liver transplant include evidence of uncal herniation, uncontrolled infection despite antibiotic therapy, multiple pressor requirement and multiorgan failure. In the United States where there is an established system of nonliving donation, the ethical dilemma of donor safety, coercion for donation, and informed consent are debated questions. Hu J, Zhang Q, Ren X, et al: Efficacy and safety of acetylcysteine in “non-acetaminophen” acute liver failure: a meta-analysis of prospective clinical trials. Mackinney-Novelo I, Barahona-Garrido J, Castillo-Albarran F, et al: Clinical course and management of acute hepatitis A infection in adults. Rosi S, Poretto V, Cavallin M, et al: Hepatic decompensation in the absence of obvious precipitants: the potential role of cytomegalovirus infection/reactivation. Santi L, Maggioli C, Mastroroberto M, et al: Acute liver failure caused by amanita phalloides poisoning. Mackiewicz A, Kotulski M, Zieniewicz K, et al: Results of liver transplantation in the treatment of Budd-Chiari syndrome. Vilstrup H, Amodio P, Bajaj J, et al: Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Kumar R, Shalimar, Sharma H, et al: Persistent hyperammonemia is associated with complications and poor outcomes in patients with acute liver failure. Murphy N, Auzinger G, Bernel W, et al: the effect of hypertonic sodium chloride on intracranial pressure in patients with acute liver failure. Caldwell S, Shah N: the prothrombin time-derived international normalized ratio: great for Warfarin, fair for prognosis and bad for liver-bleeding risk. Harry R, Auzinger G, Wendon J: the clinical importance of adrenal insufficiency in acute hepatic dysfunction. Ichai P, Legeai C, Francoz C, et al: Patients with acute liver failure listed for superurgent liver transplantation in France: reevaluation of the Clichy-Villejuif criteria. Mitchell I, Bihari D, Chang R, et al: Earlier identification of patients at risk from acetaminophen-induced acute liver failure. Jalan R, Stadlbauer V, Sen S, et al: Role of predisposition, injury, response and organ failure in the prognosis of patients with acute-on- chronic liver failure: a prospective cohort study. Kribben A, Gerken G, Haag S, et al: Effects of fractionated plasma separation and adsorption on survival in patients with acute-on- chronic liver failure. Bahirwani R, Shaked O, Bewtra M, et al: Acute-on-chronic liver failure before liver transplantation: impact on posttransplant outcomes. Yamashiki N, Sugawara Y, Tamura S, et al: Outcomes after living donor liver transplantation for acute liver failure in Japan: results of a nationwide survey. A practical approach to evaluate and treat biliary disorders using a wide array of noninvasive and invasive diagnostic and therapeutic aids is of paramount importance. The bile duct courses through or immediately adjacent to the head of the pancreas in more than 90% of patients. Bile flow into the duodenum is regulated by the sphincter of Oddi, which consists of muscle fibers that surround the distal bile duct in the wall of the duodenum at the major ampulla. A gallstone passing from the gallbladder to the duodenum would typically encounter resistance to passage in the region of the cystic duct and at the sphincter of Oddi. Bilirubin elevation may indicate an obstructive biliary process, but other processes such as sepsis, drug effects, hemolysis, or other nonbiliary etiologies should be considered for an acutely ill patient. Alkaline phosphatase elevation is not specific for biliary disease; concomitant elevation of γ- glutamyltransferase helps to confirm its hepatobiliary origin. However, an elevation in transaminases can also be seen in patients with bile duct obstruction and may precede bilirubin and alkaline phosphatase elevation in the acute setting. Noninvasive Imaging Studies Noninvasive radiologic imaging is essential for the evaluation of patients with suspected biliary tract disease. Plain Abdominal Radiograph the plain radiographic features of biliary tract disease are usually nonspecific . The most common bowel gas finding seen among patients with acute biliary disease is a generalized ileus. Air in the biliary tree may result from a biliary-enteric fistula or surgical anastomosis, prior sphincterotomy, or infection with gas- producing organisms. It is a sensitive test for determining biliary ductal dilatation, acute cholecystitis, and >95% accuracy in detecting cholelithiasis. However, it has low sensitivity (25% to 60%) for detecting choledocholithiasis  because gas in the duodenum can obscure visualization of the distal bile duct. In the presence of cholelithiasis or gallbladder sludge, the findings of ductal dilatation, elevated liver enzymes, abdominal pain, and fever are strongly suggestive of cholangitis. Findings on ultrasonography that may indicate acute gallbladder disease include focal tenderness over the gallbladder, thickening of the gallbladder wall, and pericholecystitic fluid collections, but none is specific for cholecystitis. The technique may also detect other abnormalities, including liver lesions, pancreatic masses, abscesses, or ascites. Filling the gallbladder with radionuclide confirms cystic duct patency, virtually excluding the diagnosis of acute cholecystitis. False-positive examinations can be seen in patients with chronic cholecystitis, on long- term parenteral nutrition, or after prolonged fasting. Radionuclide scanning is also useful in identifying structural abnormalities of the biliary tree, such as significant bile duct leaks; evidence of radiotracer in the abdominal cavity is diagnostic of bile leak. It has a limited role in patients with poor hepatocellular function, complete biliary obstruction, or cholangitis, each of which prevents adequate uptake or excretion of the radiopharmaceutical into the biliary tree. It also allows detailed visualization of the pancreas for grading the severity of pancreatitis and assessing its complications, such as necrosis or pseudocyst formation. Magnetic Resonance Imaging the use of magnetic resonance cholangiopancreatogram images can be manipulated to display highly accurate representations of the pancreatobiliary system with high sensitivity (88% to 96%) and specificity (93% to 100%) for the diagnosis of choledocholithiasis , strictures, and tumors. It has limited value for detecting stones <6 mm, impacted stone at the ampulla, and dilated bile duct >10 mm . Hepatobiliary scanning, on the contrary, provides physiologic information, primarily regarding patency of the cystic duct. Functional information can be especially important for patients with suspected calculous or acalculous cholecystitis. In brief, a side-viewing endoscope is passed through the mouth into the second duodenum, where the major ampulla is identified and cannulated.
One of the largest advocates in patient safety and quality has been the Leapfrog Group order chloramphenicol 250 mg line antibiotics resistant bacteria, a nonprofit organization and consortium of Fortune 500 companies that has established measures of improvement for all of healthcare  cheap chloramphenicol 500 mg otc antibiotics not working for uti. Leapfrog compliance has continued to be a priority for hospitals and includes intensivist staffing as one of its key measures buy chloramphenicol on line amex kaspersky anti-virus, or “leaps. If intensivists are unavailable, Leapfrog states that they must be reachable within 5 minutes and arrange for specifically trained nonintensivists, including nonphysicians, to reach the patient within 5 minutes. Termed a “crisis,” many critical care societies have publicly acknowledged the growing discrepancy between the supply of intensivists and the demand for critical care . Furthermore, it could have unintended consequences on other areas of healthcare that are also thought to have an inadequate number of qualified providers . Furthermore, critical illnesses such as sepsis, acute respiratory distress syndrome, acute coronary syndrome, acute cerebrovascular accidents, and venous thromboembolism require timely standardized intervention delivered by healthcare teams comprised of individuals with adequate recent experience to maintain proficiency. Telemedicine support can increase the frequency of high-quality care at locations that would have otherwise delayed care in view of the need to transport patients to locations with qualified providers. To date, this approach has not provided an adequate supply of critical care providers to solve the workforce demand. Government funding, through the creation of the Affordable Care Act , has recently initiated funding for healthcare innovation ideas across the full spectrum of healthcare delivery. In addition to the federal government, state appropriations and foundation grants have similarly appropriated funds to technology-based innovation in telehealth with the common theme of improving access to high-quality care. This is due in part to the use of dedicated workstations that run software designed to collect and display clinical information in a format that allows more efficient management of critically ill adults. These workstations include bidirectional audio/video, clinical decision support, population management software, and smart alarms and alerts that allow earlier detection of physiologic instability and abnormal laboratory values. These tools allow increased provider productivity based on the ability of the technology to collect real-time clinical data from the bedside and display electronic signatures of care need to off-site providers. Innovative critical care delivery models are gaining attention with the intention to provide safe, timely, consistent, and effective care with a limited number of qualified providers. These tools allow critical care specialists to obtain real-time actionable clinical information and provide evaluation and management services. Connecting to critically ill patients in this way can improve outcomes, lower complications, and increase patient and family satisfaction . In addition, major advances in the field of critical care medicine have produced meaningful improvements in patient survival. However, the penetration of these advances has been limited by inefficiencies of critical care delivery due to ineffective design or lack of qualified specialists . Widespread acceptance of healthcare technology into certain healthcare delivery processes has been slow because a period of diffusion of innovation is followed by rapid expansion based on social acceptance . Rapid expansion of technology and mobile communications has heightened societal expectations regarding the ability to access information anywhere, anytime, on personal electronic devices. Convenient access to healthcare is increasingly demanded, and delivery models have not fully integrated available technologies that can reduce inefficiencies, enhance the quality of care, and improve the patient experience. Because families often rate communication with providers as being as important as clinical skill , telecommunication technologies can allow families access to these valuable discussions without being present at the bedside. Anywhere, anytime connectivity can enhance integration of families into the process of critical care delivery, provide an improved family experience during an often stressful time, and reduce overutilization of invasive treatments of little clinical benefit. Over 100 years ago, attempts at electrocardiogram transmission over telephone lines allowed real-time off-site interpretation . Since the first program installation and the associated patient safety and efficiency of care benefits, there has been growth of programs with similar designs. With expanding technologies, increasing numbers of vendors, and a better understanding of the variation of designs that could potentially meet the needs of the full spectrum of urban and rural hospitals, further growth and saturation is anticipated. Recent literature provides a detailed report of various ways to utilize telemedicine support systems for the care of critically ill patients [48,69,70]. This platform provides bidirectional audio/visual capabilities, real-time interfacing and trending of physiologic data, connections to clinical information systems, and audio video connections to patients. Comparative trials of alternative systems have not been performed in part because systems that meet current telecommunications industry standards have sufficient speed and capacity to achieve nearly equivalent performance. Episodic Care Model—Proactive care that occurs intermittently connecting patient–provider or provider– provider on a predetermined basis (e. One key safety element is how the systems are designed to assure that a given intervention is prescribed to the patient for which it is intended. This tiered and shared strategy allows one intensivist to provide urgent evaluation and management services to as many as 150 critically ill adults. In addition to the networking architecture, portable and mobile solutions have emerged for both ends of the system. Mobility implies Internet connectivity because intensivists and other involved providers can use an Internet-capable laptop or mobile device to gain access to a private viewing environment. Furthermore, mobile systems are often made available on carts equipped with audio/visual and networking equipment, including some robotic systems that do not require transportation or activation by bedside providers. The availability of sophisticated technology for the delivery of critical care alone does not improve performance . Another study of the ability of off-site nurse reviews and communication to the bedside team reported significantly improved adherence to best practices . Each of the elements that were associated with improved outcomes is concordant with the safety and clinical engineering literature. Telemedicine infrastructure can allow intensivist-led teams to provide critical care expertise across a large population of patients through workflow optimization and the efficient and effective use of near real- time analyses of trending clinical information. Without technology support systems, a bedside nurse or provider must recognize and interpret complex and dynamic physiologic and clinical data before action can occur. During critical illness, vital signs, laboratory data, imaging results, and medical equipment can produce hundreds of variables occurring simultaneously. Based on current design, bedside nurses and providers are often multitasking and responding to unpredictable events elsewhere with the ability to interpret only a small fraction of the myriad of clinical information produced . Current bedside delivery often involves provider rounding and a series of individual evaluations at single points in time. This evaluation includes assessment of current biosensor and clinical information but often does not include tools to detect concerning trends of these factors that can predict deviation from the intended trajectory . With additional connectivity and interoperability among multiple bedside medical devices, such as mechanical ventilators and infusion pumps, complex interactions between patients and therapies can be acquired and interpreted utilizing electronic support . In addition, these systems allow qualified experts to interpret radiographic and ultrasonographic images in near real time. Significant effort has been placed on attempts to determine the impact of bedside intensivist staffing on patient outcomes. The inability of 24/7 intensivist models to provide incremental benefits is an important concept for the current paradigm of scarce critical care resources.