Journal of Intensive Care Medicine

Concerns over health care quality have prompted calls for the public release of performance data, or “report cards,” as one strategy for improving quality. Any initiative to create a report card should start with the selection of valid quality indicators. This is complicated by the need to account for variations in case mix among intensive care units (ICUs), the difficulty in defining which patients are receiving critical care, and the fact that pre-ICU and post-ICU care can influence the outcomes of care for ICU patients. The difficulties in measuring quality accurately make some providers reluctant to release performance data to the public, but advocates of public disclosure point to examples of improved quality after publication of report cards. Consumer and purchaser demand for report cards continues to increase, so public reporting of performance data likely will become more common. In light of this trend, it is important for physicians to become involved in the development of report cards to ensure that quality measurement is valid and that the data are used for quality improvement.

Ventricular shunts are mechanical devices used in the treatment of hydrocephalus, by means of which cerebrospinal fluid (CSF) is diverted from the ventricles to other low-pressure body cavities. Over the last 50 years, mechanical shunting has become the cornerstone for the treatment of hydrocephalus with shunt valves evolving from simple differential valves to complex programmable valves. The chief complications of ventricular shunting include obstruction, infections, and overdrainage causing subdural hematomas and slit-ventricle syndrome. As the number of commercially available valve designs continues to grow, each new generation aims at reducing the likelihood of complications, especially those resulting from overdrainage. Several studies aimed at establishing the superiority of any valve design have been conducted. All have highlighted the advantages and shortcomings of most models without conclusively providing evidence for choosing one over another. As a result, choices still rest on individual and institutional preferences.

Injured children represent a complex management problem for the trauma surgeon. Physiologic and psychological factors have been shown to influence outcome; however, more importantly, injury patterns and treatment algorithms differ from those recommended for adults. Children often do well after major injuries, but surgeons must use appropriate treatment to maximize the physiologic responses and the innate healing abilities of the growing child. Historically, surgeons have defined childhood as prepubertal, but a child's physiologic response to injury extends well into the third decade of life, making treatment of a 20-year-old similar to that of a 10-year-old, rather than that of a 40-year-old. The distribution of pediatric trauma facilities across the country has limited the access of the injured child to these centers. Adult centers more often serve as the first and definitive treatment provider for children. This article reviews the current concepts of trauma treatments for children. It is hoped that the adult trauma surgeons caring for injured children might gain information that will be of assistance in their daily practice.

This is an investigation of the association of intraoperative hypotension and perioperative myocardial infarction (MI) in low-risk patients undergoing noncardiac surgery. The case-control study compared all patients who experienced perioperative MI during the years 1996 through 1999 to a similar group of patients matched for multiple variables. Perioperative MI occurred in 22 patients. Two patients, who underwent unusual surgical procedures, were excluded from the study. The remaining 20 MI patients were compared with 40 patients who had the same types of surgery and similar mean ages, co-morbidities and preoperative evaluations. Of the patients suffering a perioperative MI, 14 (70%) experienced intraoperative hypotension, as opposed to 11 (28%) of those who did not have an MI (P = .002). Six (30%) MI patients died as opposed to only one (2.5%) of the non-MI group (P = .004). When subjected to logistic regression analysis, intraoperative hypotension remained the only significant variable associated with perioperative MI ( P = .0056). Intraoperative hypotension is associated with an increased risk of perioperative myocardial infarction and death.