Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Level 3 Paediatric Intensive Care Author(s): NHS England Publisher or Source: NHS England Type of Media: Medical Professional Education Media Originally for: Critical Care Physicians Country of Origin: United Kingdom of Great Britain and Northern Ireland (the) Primary Focus of Media: Pre-Use of PICS Designation COVID-19 Related: No Description: Paediatric Critical Care (PCC) services look after children and young people whose conditions are life-threatening and need constant close monitoring and support from equipment and medication to restore and/or maintain normal body functions. The definitions of the full range of Paediatric Critical Care is provided below. This specification specifically covers care provided in Level 3 Paediatric Critical Care (PCC) units previously known as PICUs, (Paediatric Intensive Care Units) which are usually located in tertiary centres or specialist hospitals which provide all 3 levels of PCC. However PCC level 3 units will care for patients across the whole range of PCC levels 1 – 3. PCC level 3 units provide ca re for children requiring intensive care and monitoring, including medically unstable patients requiring intubation or ventilation, single or multi-organ support, and continuous or intensive medical or nursing supervision. PCC level 3 units also provides routine planned post-operative care for surgical procedures, or during some planned medical admissions. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Chelsea physical assessment tool for evaluating functioning in post‐intensive care unit COVID‐19 patients Author(s): Alessandro de Sire, MD; Esra Giray, MD; and Ozden Ozyemisci Taskiran, MD Publisher or Source: Journal of Medical Virology Type of Media: Medical Journal Media Originally for: Critical Care Physicians,General Medical Professionals,Nurses and/or Other Critical Care Medical Professionals Country of Origin: Italy Primary Focus of Media: Post Intensive Care Syndrome (PICS) COVID-19 Related: Yes Description: By this letter, we aimed to address the need of an adequate assessment of functional status in post‐intensive care unit (ICU) coronavirus disease 2019 (COVID‐19) patients. COVID‐19 patients are at risk for post intensive care syndrome, with an impaired functional status. Physical and Rehabilitation Medicine (PRM) physicians have to face both acute and post-acute COVID‐19 patients and provide them with an adequate respiratory and neuromotor rehabilitation plan. To date, specific assessment tools are warranted to provide information regarding COVID‐19 patients' functioning. Chelsea Critical Care Physical Assessment Tool (CPAx) is a bedside assessment tool specifically designed to assess function in post‐ICU patients and has demonstrated validity, reliability, and responsiveness in critical care population. Taken together, we retain that the CPAx, due to its characteristics, might be used by PRM physicians for assessing functioning in post‐ICU COVID‐19 patients. COVID‐19 pandemic has reached more than 96.2 million of cases and more than 2 million of deaths at the moment of writing, putting under heavy stress health systems worldwide, especially ICUs. COVID‐19 survivors are at risk for post intensive care syndrome, including ICU‐acquired weakness and a consequent impairment in terms of functioning. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Protocol‐directed sedation versus non‐protocol‐directed sedation in mechanically ventilated intensive care adults and children Author(s): Leanne M Aitken, Tracey Bucknall, Bridie Kent, Marion Mitchell, Elizabeth Burmeister, Samantha J Keogh Publisher or Source: Cochrane Database of Systematic Reviews Type of Media: Medical Journal Media Originally for: Critical Care Physicians Country of Origin: Australia Primary Focus of Media: Pre-Use of PICS Designation COVID-19 Related: No Description: Background The sedation needs of critically ill patients have been recognized as a core component of critical care that is vital to assist recovery and ensure humane treatment. Evidence suggests that sedation requirements are not always optimally managed. Suboptimal sedation, both under‐ and over‐sedation, have been linked to short‐term (e.g. length of stay) and long‐term (e.g. psychological recovery) outcomes. Strategies to improve sedation assessment and management have been proposed. This review was originally published in 2015 and updated in 2018. Objectives To assess the effects of protocol‐directed sedation management compared to usual care on the duration of mechanical ventilation, intensive care unit (ICU) and hospital mortality and other patient outcomes in mechanically ventilated ICU adults and children. Search methods We used the standard search strategy of the Cochrane Anaesthesia, Critical and Emergency Care Group (ACE). We searched the Cochrane Central Register of Controlled trials (CENTRAL) (December 2017), MEDLINE (OvidSP) (2013 to December 2017), Embase (OvidSP) (2013 to December 2017), CINAHL (BIREME host) (2013 to December 2017), LILACS (2013 to December 2017), trial registries and reference lists of articles. (The original search was run in November 2013). Selection criteria We included randomized controlled trials (RCTs) and quasi‐randomized controlled trials conducted in ICUs comparing management with and without protocol‐directed sedation in intensive care adults and children. Data collection and analysis Two authors screened the titles and abstracts and then full‐text reports identified from our electronic search. We assessed seven domains of potential risk of bias for the included studies. We examined clinical, methodological and statistical heterogeneity and used the random‐effects model for meta‐analysis where we considered it appropriate. We calculated the mean difference (MD) for duration of mechanical ventilation and risk ratio (RR) for mortality across studies, with 95% confidence intervals (CIs). Main results We included four studies with a total of 3323 participants (864 adults and 2459 paediatrics) in this update. Three studies were single‐centre, patient‐level RCTs and one study was a multicentre cluster‐RCT. The settings were in metropolitan centres and included general, mixed medical‐surgical, medical only and a range of paediatric units. All four included studies compared the use of protocol‐directed sedation, specifically protocols delivered by nurses, with usual care. We rated the risk of selection bias due to random sequence generation low for two studies and unclear for two studies. The risk of bias was highly variable across the domains and studies, with the risk of selection and performance bias generally rated high and the risk of detection and attrition bias generally rated low. When comparing protocol‐directed sedation with usual care, there was no clear evidence of difference in duration of mechanical ventilation in hours for the entire duration of the first ICU stay for each patient (MD ‐28.15 hours, 95% CI ‐69.15 to 12.84; I2 = 85%; 4 studies; adjusted sample 2210 participants; low‐quality evidence). There was no clear evidence of difference in ICU mortality (RR 0.77, 95% CI 0.39 to 1.50; I2 = 67%; 2 studies; 513 participants; low‐quality evidence), or hospital mortality (RR 0.90, 95% CI 0.72 to 1.13; I2 = 10%; 3 studies; adjusted sample 2088 participants; low‐quality evidence). There was no clear evidence of difference in ICU length of stay (MD ‐1.70 days, 95% CI‐3.71 to 0.31; I2 = 82%; 4 studies; adjusted sample of 2123 participants; low‐quality of evidence), however there was evidence of a significant reduction in hospital length of stay (MD ‐3.09 days, 95% CI ‐5.08 to ‐1.10; I2 = 2%; 3 studies; adjusted sample of 1922 participants; moderate‐quality evidence). There was no clear evidence of difference in the incidence of self‐extubation (RR 0.88, 95% CI 0.55 to 1.42; I2 = 0%; 2 studies; adjusted sample of 1687 participants; high‐quality evidence), or incidence of tracheostomy (RR 0.67, 95% CI 0.35 to 1.30; I2 = 66%; 3 studies; adjusted sample of 2008 participants; low‐quality evidence). Only one study examined incidence of reintubation, therefore we could not pool data; there was no clear evidence of difference (RR 0.65, 95% CI 0.35 to 1.24; 1 study; 321 participants; low‐quality evidence). Authors' conclusions There is currently limited evidence from RCTs evaluating the effectiveness of protocol‐directed sedation on patient outcomes. The four included RCTs reported conflicting results and heterogeneity limited the interpretation of results for the primary outcomes of duration of mechanical ventilation and mortality. Further studies, taking into account differing contextual characteristics, are necessary to inform future practice. Methodological strategies to reduce the risk of bias need to be considered in future studies. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Guidelines: Post-resuscitation care Author(s): Jerry Nolan, Charles Deakin, Andrew Lockey, Gavin Perkins, Jasmeet Soar Publisher or Source: Resuscitation Council (UK) - RCUK Type of Media: Medical Professional Education Media Originally for: Critical Care Physicians,Nurses and/or Other Critical Care Medical Professionals Country of Origin: United Kingdom of Great Britain and Northern Ireland (the) Primary Focus of Media: Pre-Use of PICS Designation COVID-19 Related: No Description: Successful return of spontaneous circulation (ROSC) is the first step towards the goal of complete recovery from cardiac arrest. The complex pathophysiological processes that occur following whole body ischaemia during cardiac arrest and the subsequent reperfusion response during CPR and following successful resuscitation have been termed the post-cardiac arrest syndrome.4 Depending on the cause of the arrest, and the severity of the post-cardiac arrest syndrome, many patients will require multiple organ support and the treatment they receive during this post-resuscitation period influences significantly the overall outcome and particularly the quality of neurological recovery. The post-resuscitation phase starts at the location where ROSC is achieved but, once stabilised, the patient is transferred to the most appropriate high-care area (e.g. emergency room, cardiac catheterisation laboratory or intensive care unit (ICU) for continued diagnosis, monitoring and treatment. The post-resuscitation care algorithm (Figure 1) outlines some of the key interventions required to optimise outcome for these patients. Of those comatose patients admitted to ICUs after cardiac arrest, as many as 40–50% survive to be discharged from hospital depending on the cause of arrest, system and quality of care. Of the patients who survive to hospital discharge, the vast majority have a good neurological outcome although many have subtle cognitive impairment. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Care of ICU survivors in the community: a guide for GPs Author(s): Fiona Kiernan, MB BCh BAO, MSc (Health Econ), FCAI, EDIC, Consultant in Critical Care Medicine Publisher or Source: British Journal of General Practice Type of Media: Medical Journal Media Originally for: Former ICU Patients or Their Caregivers Country of Origin: United States Primary Focus of Media: Post Intensive Care Syndrome (PICS) COVID-19 Related: No Description: Specialists in intensive care medicine have long focused on the prevention of short-term mortality. As intensive care unit (ICU) mortality continues to improve, interest in outcome measures has expanded to include the morbidity and mortality of survivors. Over the last 10 years it has been increasingly recognised that critical illness is a medical condition itself, irrespective of the underlying cause for ICU admission, and patients experience physical, psychological, and cognitive dysfunction after hospital discharge (Figure 1). However, because relatively few patients ultimately require critical care, many GPs may have little contact with these patients. It may therefore be difficult to provide the additional support required by ICU survivors. This short paper highlights some of the physical and psychological difficulties that patients face after discharge from ICUs, and will hopefully help GPs to plan long-term management of their patients in the community. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Post-Intensive Care Syndrome and the Role of Chaplains Author(s): REV. CHELSEA LEITCHER, MDiv, BCC Publisher or Source: Catholic Health Association of the United State Type of Media: Medical Journal Media Originally for: General Public Country of Origin: United States Primary Focus of Media: Post Intensive Care Syndrome (PICS) COVID-19 Related: Yes Description: Today, a patient was discharged after an extended stay in the hospital. As we do for many patients who have survived COVID-19, we celebrated the patient's discharge. Staff who had cared for the patient lined the halls — smiling, clapping and some even had tears in their eyes. There were balloons, and a celebratory song was played over the loudspeaker as the nurse wheeled the patient to their spouse, who was eager and ready to take their loved one home at last. As a hospital chaplain, I know the value of having a case like this patient, to the family, certainly, but also to the medical community. When illness feels overwhelming, having someone who was so sick recover so beautifully changes the mood of all those who worked with them. For many staff in our hospital, this patient was our miracle — that ray of hope that reminded us even the sickest person can get better. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Anaesthetic practice in the independent sector 2018 Author(s): Guy Jackson, Paul Clyburn, Mike Nathanson, Paul Barker, Ben Greatorex, Rowan Hardy, Richard Morey, John Cousins, Jason Easby, Stephen Mannion, Sally-Ann Ryder, Ravi Gill Publisher or Source: Association of Anaesthetists Type of Media: Medical Professional Education Media Originally for: Critical Care Physicians,General Medical Professionals Country of Origin: United Kingdom of Great Britain and Northern Ireland (the) Primary Focus of Media: Pre-Use of PICS Designation COVID-19 Related: No Description: AAGBI released the first ‘Independent Practice’ guideline in 2008, intending to provide advice and guidance to consultants involved in independent practice. Working in an independent hospital provides different challenges to working within an NHS hospital, regardless of the funding for the individual patient involved. Since 2008 there has been a rapid growth in NHS-funded patients within the independent sector. The term ‘private practice’ is probably better replaced by ‘independent practice’ to more accurately reflect current activity. Now many anaesthetists find themselves delivering clinical care in independent hospitals funded from a variety of sources – NHS, private medical insurance and patient self-pay. The change in demographics of patients undergoing treatment in independent hospitals, in combination with increased regulation, brings new challenges and opportunities to anaesthetic practice. Pre-operative assessment and optimisation, and the anaesthetist as ‘peri-operative physician’, are areas that are currently often poorly addressed and remunerated within independent hospitals. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: ESPEN guideline on clinical nutrition in the intensive care unit Author(s): Pierre Singera, Annika Reintam Blaser, Mette M. Berger, Waleed Alhazzani, Philip C. Calder, Michael P. Casaer, Michael Hiesmayr, Konstantin Mayer, Juan Carlos Montejo, Claude Pichard, Jean-Charles Preiser, Arthur R.H. van Zanten, Simon Oczkowski, Wojciech Szczeklik, Stephan C. Bischoff Publisher or Source: European Society for Clinical Nutrition and Metabolism Type of Media: Medical Journal Media Originally for: Critical Care Physicians,Nurses and/or Other Critical Care Medical Professionals Country of Origin: Belgium Primary Focus of Media: Pre-Use of PICS Designation COVID-19 Related: No Description: Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: The effect of a pediatric asthma management program provided by respiratory therapists on patient outcomes and cost Author(s): Shelledy D C, McCormick S R, LeGrand T S, Cardenas J, Peters J I Publisher or Source: University of York Type of Media: Medical Journal Media Originally for: Critical Care Physicians Country of Origin: United Kingdom of Great Britain and Northern Ireland (the) Primary Focus of Media: Pre-Use of PICS Designation COVID-19 Related: No Description: Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The study examined an in-home paediatric asthma disease management programme (ADMP) provided by respiratory therapists. The ADMP consisted of eight home visits for assessment, environmental review and patient education. A detailed description of all aspects of the programme was provided. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: COVID-19 recovery: potential treatments for post-intensive care syndrome Author(s): Mansoor N Bangash, Andrew Owen, Joseph E Alderman, Minesh Chotalia, Jaimin M Patel, Dhruv Parekh Publisher or Source: The Lancet Type of Media: Medical Journal Media Originally for: Critical Care Physicians, General Medical Professionals Country of Origin: United Kingdom Primary Focus of Media: Post Intensive Care Syndrome (PICS) COVID-19 Related: Yes Description: The long-term effects of surviving COVID-19 have become a new focus of attention for clinicians and researchers. This focus has been driven partly by concerns about late ill-effects of a previously unknown virus, but recognised generic patterns of chronic disease after critical illness also exist. These patterns are termed PICS, an acronym both for post-intensive care syndrome and for persistent inflammation, immunosuppression, and catabolism syndrome. We recommend unifying post COVID-19 research aims with those of PICS research and propose a novel approach to its management by repurposing drugs that are approved, inexpensive, and safe. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Post-intensive care syndrome and COVID-19 — Implications post pandemic Author(s): Michelle Biehl, MD; and Denise Sese, MD Publisher or Source: Cleveland Clinic Journal of Medicine Type of Media: Medical Journal Media Originally for: Critical Care Physicians, General Medical Professionals, Nurses and/or Other Critical Care Medical Professionals Country of Origin: United States Primary Focus of Media: Post Intensive Care Syndrome (PICS) COVID-19 Related: Yes Description: Post-intensive care syndrome (PICS) describes new or worsening physical, cognitive, or mental impairments in a patient following critical illness or intensive care. The COVID-19 pandemic will likely result in many more patients with PICS and its associated health and economic challenges. Screening and assessment tools done during hospitalization, at discharge, and post discharge should be utilized to facilitate services and strategies to improve PICS outcomes for patient and their families. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.

Click to Return to Search Page VIEW SELECTED LIBRARY MEDIA Name of Media: Dundee ICU doctor hopes Covid-19 can ‘shine a light’ on hospital trauma Author(s): Jake Keith Publisher or Source: The Courier Type of Media: Newspaper Article Media Originally for: General Public,Nurses and/or Other Critical Care Medical Professionals Country of Origin: United Kingdom of Great Britain and Northern Ireland (the) Primary Focus of Media: Post Intensive Care Syndrome (PICS) COVID-19 Related: Yes Description: A Dundee ICU doctor hopes more can be done for those leaving intensive care after Covid-19 helped “shine a light” on the trauma suffered. To view the PDF, Article, Photo, or Chart, Click Icon: To view the attached Video media file, Click Icon: PostICU, Inc's library staff reviewed this copyrighted material contained in the library and reasonably believes that its inclusion in our library complies with the "Fair Use Doctrine" because: (1) our library's is for nonprofit and educational purposes; (2) the nature of the copyrighted work is related to our mission; (3) the amount and substantiality of the portion used in relation to the copyrighted work as a whole is fair and reasonable; and (4) the potential market for or value of the copyrighted work will if impacted, should be enhanced, by its presence in our library.