Critical Care Commons^™

Intermediate-Term Risk Of Stroke Following Cardiac Procedures In A Nationally Representative Data Set., Laura Stein, Alison Thaler, John W. Liang, Stanley Tuhrim, Amit S. Dhamoon, Mandip S. Dhamoon

Department of Neurology Faculty Papers

BACKGROUND: Studies on stroke risk following cardiac procedures addressed only perioperative and long-term risk following limited higher-risk procedures, were poorly generalizable, and often failed to stratify by stroke type. We calculated stroke risk in the intermediate risk period following cardiac procedures compared with common noncardiac surgeries and medical admissions.

METHODS AND RESULTS: The Nationwide Readmissions Database contains readmission data for 49% of US admissions in 2013. We compared age-adjusted stroke readmission rates up to 90 days postdischarge. We used Cox regression to calculate hazard ratios, up to 1 year, of stroke risk comparing transcatheter aortic valve replacement versus surgical aortic …

Critical Event Review Team (Cert), Jeffrey Kuhlman, Thomas Looke, Louis Barr, Jeanette Bartos, Gengie Nail, Brittany Almon, Joseph Keebler, Elizabeth Lazzara, Elizabeth Blickensderfer

Publications

The culture of medicine is shifting from placing blame on providers to a systems-minded culture of trying to understand human error as a symptom of deeper rooted systemic issues. The goal is to reduce harm by redesigning the systems in which humans work.

Emergency Department Repair Of Blunt Right Atrial Rupture Utilizing Cardiopulmonary Bypass, Samuel P. Carmichael, Michael C. Bounds, Alexis E. Shafii, Phillip K. Chang

Internal Medicine Faculty Publications

Blunt cardiac injury (BCI) with free wall rupture carries a high risk of pre-hospital death. Cardiopulmonary bypass (CPB) has been utilized as a bridge to repair of cardiac lesions in select patients. We present an interesting case of emergency department repair of right atrial rupture with cardiopulmonary bypass.

Caught In The Act - Migration Of A Large Right Atrial Thrombus To Pulmonary Artery During Transthoracic Echocardiography - A Case Report, Bilal Hussain, Fateh Ali Tipoo Sultan, Talha Shahzad, Sumaira Punjani

Section of Cardiology

In cases of pulmonary embolism, the visualization of a free-floating right heart thrombus on conventional transthoracic echocardiography is extremely rare. Even rarer is an echocardiographic recording of migration of a free-floating clot from the right heart into the pulmonary vasculature leading to pulmonary embolism. We present a unique case of an elderly man who presented with dyspnoea, in whom a routine 2-D bed side transthoracic echo recorded the live transit of a free floating thrombus from the right heart into the pulmonary artery resulting in pulmonary embolism. The patient remained haemodynamically stable and was managed with anticoagulation. Our case objectively …

Knowledge About Asthma: A Cross-Sectional Survey In 4 Major Hospitals Of Karachi, Pakistan, Omar Irfan, Babar Irfan, Zain Ahmad Khan, Maha Tahir, Ali Bin Sarwar Zubairi, Javaid Ahmad Khan

Section of Pulmonary & Critical Care

Objective: To determine knowledge and misconceptions about asthma among the local population..Methods: This cross-sectional study was conducted at four tertiary care hospitals; Aga Khan University Hospital, Civil Hospital Karachi, Jinnah Postgraduate Medical Centre and Ojha Institute of Chest Diseases, Karachi, from October to November 2016, and comprised hospital attendants. The questionnaire used in the study comprised 26 questions answered with a true, false or not sure answer.SPSS 20 was used for data analysis.Results: There were 400 participants. The overall mean age was 41.2±14.2 years, and 214(53.5%) of the participants were males. Moreover, 75(19%) participants thought that asthma was a psychological …

A Two-Biomarker Model Predicts Mortality In The Critically Ill With Sepsis., Carmen Mikacenic, Brenda L Price, Susanna Harju-Baker, D Shane O'Mahony, Cassianne Robinson-Cohen, Frank Radella, William O Hahn, Ronit Katz, David C Christiani, Jonathan Himmelfarb, W Conrad Liles, Mark M Wurfel

Articles, Abstracts, and Reports

RATIONALE: Improving the prospective identification of patients with systemic inflammatory response syndrome (SIRS) and sepsis at low risk for organ dysfunction and death is a major clinical challenge.

OBJECTIVES: To develop and validate a multibiomarker-based prediction model for 28-day mortality in critically ill patients with SIRS and sepsis.

METHODS: A derivation cohort (n = 888) and internal test cohort (n = 278) were taken from a prospective study of critically ill intensive care unit (ICU) patients meeting two of four SIRS criteria at an academic medical center for whom plasma was obtained within 24 hours. The validation cohort (n = …

Case Of Undiagnosed Pneumocystis Pneumonia (Pcp, Verda Arshad, Nousheen Iqbal, Haider Ali Saleem, Muhammad Irfan

Section of Pulmonary & Critical Care

Pneumocystis pneumonia (PCP) is an opportunistic fungal infection that is usually seen in immunocompromised patients, especially those with HIV, malignancies, organ transplants and on drug therapies like chemotherapy and steroids. PCP has subacute presentation in patients with AIDS which if left untreated gets worse and is a significant cause of morbidity and mortality. Here we present a case of PCP went undiagnosed, partially due to the patient being unaware of his HIV positive status and partially because no organism could be found under the microscope.

Exosomal Microrna For Detection Of Cardiac Sarcoidosis., Elliott D Crouser, Nabeel Y Hamzeh, Lisa A Maier, Mark W Julian, May Gillespie, Mohammad Rahman, David Baxter, Xiaogang Wu, S Patrick Nana-Sinkam, Kai Wang

Articles, Abstracts, and Reports

No abstract provided.

Delirium Reduction Strategies For The Critically Ill, June Chaves, Sam Canonico, Will Cheney, Tammy Corey, Gil Fraser, Alex Kowalewski, Jen Low, Cardiac Intensive Care Unit, Haley Pelletier, Cathy Palleschi, Stephen Tyzik, Suneela Nayak, Ruth Hanselman

MaineHealth Maine Medical Center

Delirium, an acute and fluctuating disturbance of consciousness and cognition, is a common manifestation of acute brain dysfunction in critically ill patients. Patients with delirium have longer hospital stays and a lower 6-month survival rate than do patients without delirium. Preliminary research suggests that delirium may be associated with cognitive impairment that persists months to years after discharge.

In a large acute care hospital, the cardiac intensive care staff became interested in mitigating their unit’s high delirium rate of ventilated patients. At baseline, many members of the healthcare team did not believe that delirium could be prevented and the predominant …

Higher Midazolam Clearance In Obese Adolescents Compared With Morbidly Obese Adults., Anne Van Rongen, Margreke J E Brill, Janelle D Vaughns, Pyry A J Välitalo, Eric P A Van Dongen, Bert Van Ramshorst, Jeffrey S Barrett, Johannes N Van Den Anker, Catherijne A J Knibbe

Anesthesiology and Critical Care Medicine Faculty Publications

Background

The clearance of cytochrome P450 (CYP) 3A substrates is reported to be reduced with lower age, inflammation and obesity. As it is unknown what the overall influence is of these factors in the case of obese adolescents vs. morbidly obese adults, we studied covariates influencing the clearance of the CYP3A substrate midazolam in a combined analysis of data from obese adolescents and morbidly obese adults.

Methods

Data from 19 obese adolescents [102.7 kg (62–149.5 kg)] and 20 morbidly obese adults [144 kg (112–186 kg)] receiving intravenous midazolam were analysed, using population pharmacokinetic modelling (NONMEM 7.2). In the covariate analysis, …

Data On The Effect Of Sex On The Size, Cellular Content, And Neuronal Density Of The Developing Brain In Mice Exposed To Isoflurane And Carbon Monoxid, L Wang, A Wang, W W. Supplee, K Koffler, Y Cheng, Z M.N. Quezado, R J. Levy

Anesthesiology and Critical Care Medicine Faculty Publications

The data presented here detail the changes in size, cellular content, and neuronal density of the developing brain over time with respect to sex in C57Bl/6 mice following neonatal exposure to isoflurane, carbon monoxide, or their combination. Specifically, brain weight- and brain volume-to-body weight ratios are presented, representative immunoblots of whole brain cell-specific protein content are depicted, and quantification of the number of neurons in the primary somatosensory cortex and CA3 region of the hippocampus are shown. Three discrete postnatal time points are represented: P7 (prior to exposure), P14 (one-week post exposure), and P42-56 (5–7 weeks post exposure). Major findings …

Protocol Adherence For Continuously Titrated Interventions In Randomized Trials: An Overview Of The Current Methodology And Case Study., F Lauzier, N K Adhikari, A Seely, K K Y Koo, E P Belley-Côté, K E A Burns, D J Cook, F D'Aragon, B Rochwerg, M E Kho, S J W Oczkowksi, E H Duan, M O Meade, A G Day, F Lamontagne

Articles, Abstracts, and Reports

BACKGROUND: The standard definition for protocol adherence is the proportion of all scheduled doses that are delivered. In clinical research, this definition has several limitations when evaluating protocol adherence in trials that study interventions requiring continuous titration.

DISCUSSION: Building upon a specific case study, we analyzed a recent trial of a continuously titrated intervention to assess the impact of different definitions of protocol deviations on the interpretation of protocol adherence. The OVATION pilot trial was an open-label randomized controlled trial of higher (75-80 mmHg) versus lower (60-65 mmHg) mean arterial pressure (MAP) targets for vasopressor therapy in shock. In this …

Spectrum Of Interstitial Lung Disease From A Tertiary Care Hospital In Karachi, Ali Bin Sarwar Zubairi, Maryam Hassan, Talha Shahzad, Sajjad Sarwar, Aamir Abbas, Huzaifa Ahmad, Muhammad Irfan

Section of Pulmonary & Critical Care

Objective: To determine the clinical features and patterns of interstitial lung disease.
Methods: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised record of patients diagnosed with interstitial lung disease from January 2005 to December 2015. All patients aged 16 years and above diagnosed with interstitial lung disease on the basis of clinical features, radiological features on high-resolution computed tomography of the chest, and lung biopsies were included. SPSS 19 was used for data analysis.
Results: Of the 537 patients, 324(60.3%) of the participants were females. The overall mean age was 60.5±14.9 years. The most …

Pharmacological Threat To Lungs: A Case Series And Literature Review, Omar Irfan, Jaleed A. Gilani, Abeel Irshad, Babar Irfan, Javaid A. Khan

Section of Pulmonary & Critical Care

Drug-induced organ damage stands as a prevalent yet much-neglected issue globally. Keeping in view it's rising frequency, health care providers stand obliged to be well versed with the de-merits of the agents they prescribe. Drug therapies causing damage present with a non-specific clinical presentation, histological findings or radiology, which further elaborates on the necessity of a conscientious diagnosis. Pulmonary architecture ranging from the airways, lung parenchyma, mediastinum, pleura, pulmonary vasculature or the neuromuscular system, all can fall victim to the dreaded outcomes of this menace. In order to establish successful diagnosis, the definite temporal relation between initiation of drug therapy …

Subanesthetic Ketamine For Pain Management In Hospitalized Children, Adolescents, And Young Adults: A Single-Center Cohort Study, K A. Sheehy, C Lippoid, A L. Rice, R Nobrega, Julia C. Finkel, Zenaide Quezado

Anesthesiology and Critical Care Medicine Faculty Publications

¹Division of Anesthesiology, Pain, and Perioperative Medicine, The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s Research Institute, Children’s National Health System, George Washington University School of Medicine and Health Sciences, ²Center for Neuroscience Research, Children’s Research Institute, Children’s National Health System, Washington, DC, USA *These authors contributed equally to this work Background: Subanesthetic doses of ketamine, an N-methyl-D-aspartate receptor antagonist used as an adjuvant to opioid for the treatment of pain in adults with acute and chronic pain, have been shown, in some instances, to improve pain intensity and to decrease opioid intake. However, less is …

Glucocorticoid Receptor Polymorphisms And Outcomes In Pediatric Septic Shock., Natalie Z. Cvijanovich, Nick Anas, Geoffrey L. Allen, Neal J. Thomas, Michael T. Bigham, Scott L. Weiss, Julie Fitzgerald, Paul A. Checchia, Keith Meyer, Michael Quasney, Rainer Gedeit, Robert J. Freishtat, Jeffrey Nowak, Shekhar S. Raj, Shira Gertz, Jocelyn R. Grunwell, Amy Opoka, Hector R. Wong

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVE: Polymorphisms of the glucocorticoid receptor gene are associated with outcome and corticosteroid responsiveness among patients with inflammatory disorders. We conducted a candidate gene association study to test the hypothesis that these polymorphisms are associated with outcome and corticosteroid responsiveness among children with septic shock.

DESIGN: We genotyped 482 children with septic shock for the presence of two glucocorticoid receptor polymorphisms (rs56149945 and rs41423247) associated with increased sensitivity and one glucocorticoid receptor polymorphism (rs6198) associated with decreased sensitivity to corticosteroids. The primary outcome variable was complicated course, defined as 28-day mortality or the persistence of two or more organ failures …

Multiple Organ Dysfunction In Children Mechanically Ventilated For Acute Respiratory Failure., Scott L. Weiss, Lisa A. Asaro, Heidi R. Flori, Geoffrey L. Allen, David Wypij, Martha A Q Curley, Randomized Evaluation Of Sedation Titration For Respiratory Failure (Restore) Study Investigators

Manuscripts, Articles, Book Chapters and Other Papers

OBJECTIVES: The impact of extrapulmonary organ dysfunction, independent from sepsis and lung injury severity, on outcomes in pediatric acute respiratory failure is unclear. We sought to determine the frequency, timing, and risk factors for extrapulmonary organ dysfunction and the independent association of multiple organ dysfunction syndrome with outcomes in pediatric acute respiratory failure.

DESIGN: Secondary observational analysis of the Randomized Evaluation of Sedation Titration for Respiratory Failure cluster-randomized prospective clinical trial conducted between 2009 and 2013.

SETTING: Thirty-one academic PICUs in the United States.

PATIENTS: Two thousand four hundred forty-nine children mechanically ventilated for acute respiratory failure enrolled in Randomized …

Cigarette Smoke Impairs A2a Adenosine Receptor Mediated Wound Repair Through Up-Regulation Of Duox-1 Expression., Zhi Tian, Hui Zhang, Jendayi Dixon, Nicole Traphagen, Todd A. Wyatt, Kusum K. Kharbanda, Samantha Simet, Narasaiah Kolliputi, Diane S Allen-Gipson

Journal Articles: Pulmonary & Critical Care Med

Cigarette smoke (CS) exposure and intrinsic factors such as the NADPH oxidases produce high levels of reactive oxygen species (ROS), ensuing inflammatory tissue injury. We previously demonstrated that CS-generated ROS, particularly hydrogen peroxide (H2O2), impaired adenosine stimulated wound repair. We hypothesized that CS exposure modulates expression of Dual oxidase 1 (Duox-1), a NADPH oxidases known to generate H2O2. To test this hypothesis, we used human bronchial epithelial cell line Nuli-1 and C57BL/6 mice. Cells were treated with 5% CS extract (CSE) for various periods of time, and mice were exposed to whole body CS for six weeks. Both CSE and …

Effect Of Low-Level Co2 On Innate Inflammatory Protein Response To Organic Dust From Swine Confinement Barns., David Schneberger, Jane M. Devasure, Kristina L. Bailey, Debra J. Romberger, Todd A. Wyatt

Journal Articles: Pulmonary & Critical Care Med

BACKGROUND: Organic hog barn dust (HDE) exposure induces lung inflammation and long-term decreases in lung function in agricultural workers. While concentrations of common gasses in confined animal facilities are well characterized, few studies have been done addressing if exposure to elevated barn gasses impacts the lung immune response to organic dusts. Given the well documented effects of hypercapnia at much higher levels we hypothesized that CO2 at 8 h exposure limit levels (5000 ppm) could alter innate immune responses to HDE.

METHODS: Using a mouse model, C57BL/6 mice were nasally instilled with defined barn dust extracts and then housed in …

Effect Of Low-Level Co2 On Innate Inflammatory Protein Response To Organic Dust From Swine Confinement Barns., David Schneberger, Jane M. Devasure, Kristina L. Bailey, Debra J. Romberger, Todd A. Wyatt

Journal Articles: Pulmonary & Critical Care Med

BACKGROUND: Organic hog barn dust (HDE) exposure induces lung inflammation and long-term decreases in lung function in agricultural workers. While concentrations of common gasses in confined animal facilities are well characterized, few studies have been done addressing if exposure to elevated barn gasses impacts the lung immune response to organic dusts. Given the well documented effects of hypercapnia at much higher levels we hypothesized that CO2 at 8 h exposure limit levels (5000 ppm) could alter innate immune responses to HDE.

METHODS: Using a mouse model, C57BL/6 mice were nasally instilled with defined barn dust extracts and then housed in …

Facing The Ongoing Challenge Of The Febrile Young Infant., Adrienne G. Deporre, Paul L. Aronson, Russell J. Mcculloh

Manuscripts, Articles, Book Chapters and Other Papers

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at http://ccforum.com/series/annualupdate2017 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

Waiting 2 Minutes After Sucrose Administration—Unnecessary?, Naomi Meesters, Sinno Simons, Joost Van Rosmalen, Irwin Reiss, John Van Den Anker, Monique Van Dijk

Pediatrics Faculty Publications

Background Worldwide, oral sucrose is standard of care in many neonatal intensive care units to relieve procedural pain in neonates. This study aims to determine if time interval between sucrose administration and heelstick correlates with pain scores.

Methods Neonates were prospectively studied with variable time intervals and assessed with the Premature Infant Pain Profile-Revised (PIPP-R).

Results 150 neonates were included with a median gestational age of 30⁺⁶ (IQR 27⁺⁶–33⁺²) weeks and a median time interval of 72 (IQR 39–115) seconds between sucrose administration and heelstick. In multiple regression analysis, this time interval was not significantly …

Hypoxia Inducible Factor 1: A Urinary Biomarker Of Kidney Disease., S Movafagh, Dominic Raj, M Sanaei-Ardekani, D Bhatia, K Vo, M Mahmoudieh, R Rahman, E H Kim, Arthur F Harralson

Medicine Faculty Publications

Identifying noninvasive biomarkers of kidney disease is valuable for diagnostic and therapeutic purposes. Hypoxia inducible factor 1 (HIF-1) expression is known to be elevated in the kidneys in several renal disease pathologies. We hypothesized that the urinary HIF-1a mRNA level may be a suitable biomarker for expression of this protein in chronic kidney disease (CKD). We compared HIF-1a mRNA levels from urine pellets of CKD and healthy subjects. To ensure that urinary HIF-1a mRNA is of kidney origin, we examined colocalization of HIF-1a mRNA with two kidney specific markers in urine cells. We found that HIF-1a mRNA is readily quantifiable …

Interhospital Transfer Of Children In Respiratory Failure: A Clinician Interview Qualitative Study., Folafoluwa O. Odetola, Renee R. Anspach, Yong Y. Han, Sarah J. Clark

Manuscripts, Articles, Book Chapters and Other Papers

PURPOSE: To investigate the decision making underlying transfer of children with respiratory failure from level II to level I pediatric intensive care unit care.

METHODS: Interviews with 19 eligible level II pediatric intensive care unit physicians about a hypothetical scenario of a 2-year-old girl in respiratory failure: RESULTS: At baseline, indices critical to management were as follows: OI (53%), partial pressure of oxygen in arterial blood (Pao

CONCLUSION: Interhospital transfer of children in respiratory failure is triggered by poor response to escalation of locally available care modalities. This finding provides new insight into decision making underlying interhospital transfer of children …

Does Medication Safety And Diversion Education Improve Medication Securement Practices In Scu Compared To Current Practice?, Natasha Stankiewicz

Interprofessional Research and Innovations Council

This safety quality improvement project began as newly hired SCU2 team members saw an opportunity to improve our medication safety practices and culture. The convenience of having certain medications directly available at bedside was priority. There was a lack of awareness and interest in securing medications within the department. However, the risk to our patients, families, visitors and colleagues when medications are left out, available and unsecured was apparent to new staff and others. Prior to our education, the accepted practice of unsecured medications was rampant: medications were left drawn up or exposed, setting in various open areas at bedside …

Development Of A Traumatic Brain Injury (Tbi) Order Set At Maine Medical Center, Sarah Bockian, Emily Esslinger, Martha Weatherhead

Interprofessional Research and Innovations Council

Background: Traumatic brain injury (TBI) occurs when an external force causes brain dysfunction. TBI management in the critical care setting focuses on treating the initial, or primary brain injury, as well as secondary injuries, caused by hypoxia, hypotension, and swelling. Due to the lack of consensus within the literature, in addition to numerous attending and resident physicians at Maine Medical Center (MMC), variability in care often occurs. Nursing staff within the neuro-intensive care unit at MMC noticed this variability, and approached leadership within the surgical-trauma service to create an order set focused on TBI management.

Purpose: In the TBI population, …