Critical Care Commons^™

Transfer Of Patients With St Elevation Myocardial Infarction For Primary Percutaneous Coronary Intervention During Ordinary & Pandemic Times Position Statement Of The Saudi Arabian Cardiac Intervention Society, Shukri M. Al Saif, Owayed Al Shammeri, Abdullah Alkhushail, Ramzi Almohammadi, Mohamed Kurdi

Journal of the Saudi Heart Association

Primary percutaneous coronary intervention is the most effective therapy in the management of acute ST Elevation Myocardial Infarction. Evidence recommends keeping the period from symptom onset to reperfusion to a minimum in order to preserve left ventricular function, improve outcome, and reduce mortality. The position statement describes the recommendations of the the Saudi Arabian Cardiac Intervention Society for optimal conditions and timing for the acute management of patients presenting with ST Elevation Myocardial Infarction during ordinary and pandemic times.

Pulling Heart Strings: Quality Improvement Algorithm For Temporary Epicardial Pacing Wire Removal Post Cardiac Surgery, Jessica Norman

Doctors of Nursing Practice (DNP) Final Projects, 2020-current

The placement of temporary epicardial pacing wires (TEPW) is considered standard practice post cardiac surgery and is dependent on the patient’s cardiac function intra-operatively and their electrophysiologic profile after weaning from cardiopulmonary bypass (Reade, 2007; Elmistekawy et al, 2016). Complications associated with TEPW removal include myocardial damage, infection, perforation, tamponade, disruption of anastomoses, ventricular arrythmias, and death (Bojar, 2009; Carroll et al, 1998;Timothy & Rodeman, 2004). Currently there is no standard practice on the removal of TEPW and there is wide variation in removal practices involving patients who are routinely on medications such as dual antiplatelet therapies and systemic anticoagulation. …

Covid Intensive Care Unit Through The Eyes Of Ophthalmologists, Laura Drayer Turner, Dharshana Ramanathan, Sneha Melmane, Geeta Menon

HCA Healthcare Journal of Medicine

The disproportionate impact of COVID on the mortality and morbidity of people of black, Asian and minority ethnic (BAME) backgrounds has been recognised and is under investigation. Here we present a different impact: that on the psyche. As three doctors of BAME heritage, we shared an experience of being redeployed from ophthalmology to the COVID Intensive Care Unit. We share our reflections on the experience and lessons learned.

Extracorporeal Membrane Oxygenation For Covid-19 Treatment In A Community Hospital, Daniel I. Loube, Kashif Z. Hassan, Sang H. Lee

HCA Healthcare Journal of Medicine

Coronavirus disease 2019 (COVID-19) may result in severe acute respiratory disease syndrome (ARDS) and death. For COVID-19 patients failing mechanical ventilation, extra corporeal membrane oxygenation (ECMO) has been used with varying efficacy in academic medical centers and quaternary referral centers. We report the successful use of veno-venous (VV) ECMO to treat refractory ARDS due to COVID-19 in a community hospital setting with a survival to discharge rate of 71% over a 3 month period. In a community hospital with adequate resources, VV ECMO can be an effective rescue therapy for selected COVID-19 patients who fail all other available treatments.

Anesthetic Use In Status Epilepticus: A Concise Review, Furkan M. Yilmaz, Lauren A. Igneri, Yasir A. Yilmaz, Evren Burakgazi-Dalkilic

Cooper Rowan Medical Journal

The purpose of this review is to summarize the recent literature focusing on intravenous (IV) administration of commonly used anesthetics, including midazolam, pentobarbital/ thiopental, propofol, and ketamine in the treatment of status epilepticus (SE). Anesthetics should be reserved as third-line therapy for the treatment of SE when benzodiazepines and other second-line agents fail to terminate the seizure. We have reviewed the literature related to the treatment of status epilepticus, refractory status epilepticus, super-refractory status epilepticus, anesthetics, midazolam, pentobarbital/thiopental, propofol, and ketamine. This paper focuses on the pharmacology, dosages, major side effects, and clinical use of IV anesthetics in the treatment …

Development, Expansion And Role Of Myeloid-Derived Suppressor Cells In Post-Sepsis Immune Suppression, Tuqa Alkhateeb

Electronic Theses and Dissertations

Myeloid-derived suppressor cells (MDSCs) numbers increase significantly in sepsis and are associated with high mortality rates. These myeloid cell precursors promote immunosuppression, especially in the late (post sepsis) stage. However, the mechanisms that underlie MDSC expansion and programming are not completely understood. To investigate these mechanisms, we used a cecal-ligation and puncture (CLP) mouse model of polymicrobial sepsis that progresses from an early/acute proinflammatory phase to a late/chronic immunosuppressive phase. Previous studies in our laboratory showed that microRNA (miR)-21 and miR-181b elevate levels of the transcription factor nuclear factor 1 (NFI-A) that promotes MDSC expansion. We report here that miR-21 …

Coverage Of The 2019 Eastern Equine Encephalitis Virus Outbreak On News Media, Corey H. Basch, Joseph Fera, Christie Jaime, Nasia Quininoes

Publications and Research

Background: The media plays as an important role in delivering information about emergent issues, such as the Eastern equine encephalitis virus (EEEV) outbreak of 2019. As such, there has been an increase in news coverage of vector-borne disease coverage due to a rise in emerging or re-emerging arboviruses.

Methods: The purpose of this study was to describe the content of news clips related to the recent (2019) EEEV outbreak in the United States.

Results: Only 3 of the important topics identified were mentioned in a majority of the 110 videos analyzed. These topics were, mosquito mentioned as transmitter, prevention by …

A Fatal Rectus Sheath Hematoma After A Myasthenia Crisis Case Report, Robert G. Michaud, Lesley B. Gordon

Journal of Maine Medical Center

Introduction: Rectus sheath hematomas (RSH) generally occur due to damage to the inferior epigastric artery. They are rare causes of abdominal pain or acute blood loss anemia, but are an important diagnostic consideration because they can be cryptic and are potentially fatal.

Clinical Findings: An 85-year-old female who had been admitted to the hospital for 10 days with a myasthenia crisis was found to be abruptly hypotensive with a tender abdominal mass in the left lower quadrant subtly crossing midline. She was on prophylactic anticoagulation during her hospitalization.

Main diagnosis, therapeutics, interventions, and outcomes: The patient was initially stabilized with …

Isolated Polymorphic Ventricular Tachycardia: An Unusual Presentation Of Acute Myocarditis, Natalie S. Shwaish

Research Days

No abstract provided.

Angiopoietin 1 Protects Against Lps-Induced Acute Lung Injury And Alveolar Remodeling In Neonatal Mice, Umar Salimi

Research Days

No abstract provided.

Current Smoking With Or Without Chronic Bronchitis Is Independently Associated With Goblet Cell Hyperplasia In Healthy Smokers And Copd Subjects, Victor Kim, Stephanie Jeong, Huaqing Zhao, Mehmet Kesimer, Richard C. Boucher, J. Michael Wells, Stephanie A. Christenson, Meilan K. Han, Mark Dransfield, Robert Paine, Christopher B. Cooper, Igor Barjaktarevic, Russell Bowler, Jeffrey L. Curtis, Robert J. Kaner, Sarah L. O'Beirne, Wanda K. O'Neal, Stephen I. Rennard, Fernando J. Martinez, Prescott G. Woodruff

Journal Articles: Pulmonary & Critical Care Med

COPD, chronic bronchitis (CB) and active smoking have all been associated with goblet cell hyperplasia (GCH) in small studies. Active smoking is strongly associated with CB, but there is a disconnect between CB clinical symptoms and pathology. Chronic cough and sputum production poorly correlate with the presence of GCH or COPD. We hypothesized that the primary determinant of GCH in ever smokers with or without airflow obstruction is active smoking. Goblet Cell Density (GCD) was measured in 71 current or former smokers [32 subjects without COPD and 39 COPD subjects]. Endobronchial mucosal biopsies were stained with Periodic Acid Schiff-Alcian Blue, …

Co-Morbidity Patterns Identified Using Latent Class Analysis Of Medications Predict All-Cause Mortality Independent Of Other Known Risk Factors: The Copdgene® Study, Yisha Li, Margaret Ragland, Erin Austin, Kendra Young, Katherine Pratte, John E. Hokanson, Terri H Beaty, Elizabeth A. Regan, Stephen I. Rennard, Christina Wern, Michael R. Jacobs, Ruth Tal-Singer, Barry J. Make, Gregory L. Kinney, Copdgene Investigators

Journal Articles: Pulmonary & Critical Care Med

PURPOSE: Medication patterns include all medications in an individual's clinical profile. We aimed to identify chronic co-morbidity treatment patterns through medication use among COPDGene participants and determine whether these patterns were associated with mortality, acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and quality of life.

MATERIALS AND METHODS: Participants analyzed here completed Phase 1 (P1) and/or Phase 2 (P2) of COPDGene. Latent class analysis (LCA) was used to identify medication patterns and assign individuals into unobserved LCA classes. Mortality, AECOPD, and the St. George's Respiratory Questionnaire (SGRQ) health status were compared in different LCA classes through survival analysis, logistic …

Blood Eosinophil Counts In Clinical Trials For Chronic Obstructive Pulmonary Disease, Dave Singh, Mona Bafadhel, Christopher E. Brightling, Frank C. Sciurba, Jeffrey L. Curtis, Fernando J. Martinez, Cara B. Pasquale, Debora D. Merrill, Norbert Metzdorf, Stefano Petruzzelli, Ruth Tal-Singer, Christopher Compton, Stephen I. Rennard, Ubaldo J. Martin

Journal Articles: Pulmonary & Critical Care Med

No abstract provided.

Heme Metabolism Genes Downregulated In Copd Cachexia, Ava C. Wilson, Preeti L. Kumar, Sool Lee, Margaret M. Parker, Itika Arora, Jarrett D. Morrow, Emiel F.M. Wouters, Richard Casaburi, Stephen I. Rennard, David A. Lomas, Alvar Agusti, Ruth Tal-Singer, Mark T. Dransfield, J. Michael Wells, Surya P. Bhatt, George Washko, Victor J. Thannickal, Hemant K. Tiwari, Craig P. Hersh, Peter J. Castaldi, Edwin K. Silverman, Merry-Lynn N. Mcdonald

Journal Articles: Pulmonary & Critical Care Med

INTRODUCTION: Cachexia contributes to increased mortality and reduced quality of life in Chronic Obstructive Pulmonary Disease (COPD) and may be associated with underlying gene expression changes. Our goal was to identify differential gene expression signatures associated with COPD cachexia in current and former smokers.

METHODS: We analyzed whole-blood gene expression data from participants with COPD in a discovery cohort (COPDGene, N = 400) and assessed replication (ECLIPSE, N = 114). To approximate the consensus definition using available criteria, cachexia was defined as weight-loss > 5% in the past 12 months or low body mass index (BMI) (<  20 kg/m

RESULTS: The prevalence of …

Improving The Evaluation Of Copd Exacerbation Treatment Effects By Accounting For Early Treatment Discontinuations: A Post-Hoc Analysis Of Randomized Clinical Trials., Agnieszka Król, Robert Palmér, Virginie Rondeau, Stephen I. Rennard, Ulf G. Eriksson, Alexandra Jauhiainen

Journal Articles: Pulmonary & Critical Care Med

BACKGROUND: Chronic obstructive pulmonary disease (COPD) clinical trials aimed at evaluating treatment effects on exacerbations often suffer from early discontinuations of randomized treatment. Treatment discontinuations imply a loss of information and should ideally be considered in the statistical analysis of trial results, particularly if the discontinuations are related to the disease or treatment itself. Here, we explore this issue by investigating (1) whether there exists an association between the risks of exacerbation and treatment discontinuation in COPD clinical trials and (2) whether disregarding this association can cause bias in exacerbation treatment effect estimates. We focus on the hypothetical estimand, i.e. …

Agonist-Specific Desensitization Of Pge2-Stimulated Camp Signaling Due To Upregulated Phosphodiesterase Expression In Human Lung Fibroblasts, Francisco J. Nunez, Nancy Schulte, David M. Fogel, Joel Michalski, Stephen I. Rennard, Raymond B. Penn, Myron L. Toews, Rennolds S. Ostrom

Journal Articles: Pulmonary & Critical Care Med

Pulmonary fibrosis is characterized by fibroblasts persisting in an activated form, producing excessive fibrous material that destroys alveolar structure. The second messenger molecule cyclic 3',5'-adenosine monophosphate (cAMP) has antifibrotic properties, and prostaglandin E2 (PGE2) can stimulate cAMP production through prostaglandin E (EP)2 and EP4 receptors. Although EP receptors are attractive therapeutic targets, the effects of long-term exposure to PGE2 have not been characterized. To determine the effects of long-term exposure of lung fibroblasts to PGE2, human fetal lung (HFL)-1 cells were treated for 24 h with 100 nM PGE2 or other cAMP-elevating agents. cAMP levels stimulated by acute exposure to …

Endothelial Injury And Glycocalyx Degradation In Critically Ill Coronavirus Disease 2019 Patients: Implications For Microvascular Platelet Aggregation, Douglas Fraser

Data and Test Instruments

No abstract provided.

Implications Of Frailty In Copd Exacerbations, Aimee Almanzar, Armando Cabrera, Felix Hernandez, Hector Y. Vazquez, Asma Jafri, Miriam Zylberglait Lisigurski, Livasky Concepcion, Gustavo Ferrer

Pulmonary Disease

Introduction The extrapulmonary manifestations of chronic obstructive pulmonary disease (COPD) patients are similar to symptoms of frailty, a geriatric syndrome. This study was designed to identify the relation between frailty and patient outcomes during a COPD exacerbation. Methods This retrospective study identified 10,235 patients hospitalized for COPD exacerbation, as well as 16 laboratory tests included in a frailty index that have been linked to frailty. Patients were divided into less frail (0-8 positive laboratory values) and more frail (9-16 positive laboratory values) groups. The primary composite endpoints were mechanical ventilation, ICU length of stay, readmission, and discharge status. Results Of …

Anesthetic Management Without The Use Of Neuromuscular Blocking Agents In Myasthenia Gravis Patient Undergoing Coronary Artery Bypass Grafting And Thymectomy, Katarina Kapisoda, Ettore Crimi Md, Omeni Osian

Anesthesiology

We describe a novel and effective anesthetic management of a 67 year old male with myasthenia gravis (MG) who underwent combined coronary artery bypass graft and thymectomy. Induction of general anesthesia with endotracheal intubation was performed with propofol and remifentanyl without use of any neuromuscular blocking agents (NMBA). General anesthesia was then maintained with inhaled isoflurane and continuous intravenous infusion of sufentanyl and dexmedetomidine. In ICU, trachea was extubated within two hours from admission and no complications occurred during the following 24 hours ICU stay. Avoidance of NMBA may improve outcomes by decreasing the risks associated with their use.

End Tidal Carbon Dioxide Monitoring (Capnography) In The Cardiac Intensive Care Unit, Madeline Elaine Huff, Kenneth T. Shelton

School of Medicine Publications

Background: Carbon dioxide levels can be monitored throughout the respiratory cycle via capnography. In this way, capnography allows healthcare professionals to follow several respiratory factors in real-time, including respiratory depression, apnea, and hypercapnia. Postoperative patients are subjected to significant harm while receiving sedating medications without appropriate monitoring and intervention. Earlier detection of alterations to ventilation status will better enable providers to more accurately dose medications during procedures, especially in high-risk patient populations.

Methods: Patient selection included post-operative patients in the intensive care unit that were receiving sedation/analgesia, high dose or high frequency opioids, epidural or intrathecal pain management, patients that …

Lighting The Way To Ensure Safe Transition Home, Barb Haney, Ashley Mirabile, Dianne Wilderson, Beckie Palmer, Ashley Lewis, Cris Mills, Eugenia K. Pallotto

Posters

All aspects of discharge (education, screenings, appointments, plans and home services" must be completed and appropriately communicated prior to discharge to ensure safe transition to home.

Goal: Standardize all aspects of discharge in a large, busy 84-bed Level IV NICU with >1000 admissions/year and >300 nurses, >60 NNPs, and >25 neonatologists.

• 95% of patients with lengths of stay >3 days have all discharge planning completed prior to discharge/Parent Care Unit overnight stay

Clabsi Prevention Through Prevention Huddles And Clabsi Risk Assessment And Prevention Form In Electronic Medical Record, Tara Benton, Barb Haney, Lacey Bergerhofer, Yolanda Ballam, Kaitlyn Hoch

Posters

Our aim is to increase the awareness of high risks for central line associated bloodstream infection (CLABSI) and decrease the CLABSI rate with the implementation of CLABSI prevention huddles and an electronic medical record (EMR) "CLABSI Risk Assessment and Prevention" form.

Who Codes In The Nicu: An Analysis Of Demographics And Factors That Place Neonates At Higher/Lower Risk Of A Serious Code Event And Prognosis Post-Code, Danielle N. Gonzales, Ashley K. Sherman, Jennifer Dremann, Staci Elliott, Amelia Gute, Amber Bellinghausen, Jessica Brunkhorst, Danielle Reed

Posters

This study analyzed resuscitation events in a level IV neonatal intensive care unit from 2012-2017 to determine whether there are identifiable differences between those who have a rapid response event and those with a short or long code and determine factors post-event that may impact survival to discharge.

Tgf-Β Induces A Heart Failure Phenotype Via Fibroblasts Exosome Signaling, Hesham Basma, Adelaide N. Johanson, Kajari Dhar, Daniel R. Anderson, Fang Qiu, Stephen I. Rennard, Brian D. Lowes

Journal Articles: Pulmonary & Critical Care Med

PURPOSE: The mechanisms for persistent and progressive loss of myocardial function in advanced heart failure (HF) remain incompletely characterized. In the current study, we sought to determine the impact of TGF-β on fibroblasts transcriptional profiles and assess if exosomes from TGF-β treated fibroblasts could induce a heart failure phenotype in co-cultured cardiomyocytes.

METHOD: Normal heart fibroblasts were treated with TGF-β with a final conc. of 2.5 ng/ml in serum free media. HF fibroblasts were also obtained from patients undergoing implantation of left ventricular assist devices. Exosomes were collected using three-step ultracentrifugation. Cardiomyocytes were co-cultured with exosomes from TGF-β-treated, HF and …

Bronchoalveolar Lavage Fluid From Copd Patients Reveals More Compounds Associated With Disease Than Matched Plasma, Eitan Halper-Stromberg, Lucas Gillenwater, Charmion Cruickshank-Quinn, Wanda Kay O'Neal, Nichole Reisdorph, Irina Petrache, Yonghua Zhuang, Wassim W. Labaki, Jeffrey L. Curtis, James Wells, Stephen I. Rennard, Katherine A. Pratte, Prescott Woodruff, Kathleen A. Stringer, Katerina Kechris, Russell P. Bowler

Journal Articles: Pulmonary & Critical Care Med

Smoking causes chronic obstructive pulmonary disease (COPD). Though recent studies identified a COPD metabolomic signature in blood, no large studies examine the metabolome in bronchoalveolar lavage (BAL) fluid, a more direct representation of lung cell metabolism. We performed untargeted liquid chromatography-mass spectrometry (LC-MS) on BAL and matched plasma from 115 subjects from the SPIROMICS cohort. Regression was performed with COPD phenotypes as the outcome and metabolites as the predictor, adjusted for clinical covariates and false discovery rate. Weighted gene co-expression network analysis (WGCNA) grouped metabolites into modules which were then associated with phenotypes. K-means clustering grouped similar subjects. We detected …

It's More Than Low Bmi: Prevalence Of Cachexia And Associated Mortality In Copd, Merry-Lynn N. Mcdonald, Emiel F.M. Wouters, Erica Rutten, Richard Casaburi, Stephen I. Rennard, David A. Lomas, Marcas Bamman, Bartolome Celli, Alvar Agusti, Ruth Tal-Singer, Craig P. Hersh, Mark Dransfield, Edwin K. Silverman

Journal Articles: Pulmonary & Critical Care Med

BACKGROUND: Cachexia is associated with increased mortality risk among chronic obstructive pulmonary disease (COPD) patients. However, low body mass index (BMI) as opposed to cachexia is often used, particularly when calculating the BODE (BMI, Obstruction, Dyspnea and Exercise) index. For this reason, we examined mortality using a consensus definition and a weight-loss definition of cachexia among COPD cases and compared two new COPD severity indices with BODE.

METHODS: In the current report, the consensus definition for cachexia incorporated weight-loss > 5% in 12-months or low BMI in addition to 3/5 of decreased muscle strength, fatigue, anorexia, low FFMI and inflammation. The …

Prospective Observational Study In Patients With Obstructive Lung Disease: Novelty Design, Helen K. Reddel, Maria Gerhardsson De Verdier, Alvar Agustí, Gary Anderson, Richard Beasley, Elisabeth H. Bel, Christer Janson, Barry Make, Richard J. Martin, Ian Pavord, David Price, Christina Keen, Asparuh Gardev, Stephen I. Rennard, Alecka Sveréus, Aruna T. Bansal, Lance Brannman, Niklas Karlsson, Javier Nuevo, Fredrik Nyberg, Simon S. Young, Jørgen Vestbo

Journal Articles: Pulmonary & Critical Care Med

Asthma and chronic obstructive pulmonary disease (COPD) have overlapping clinical features and share pathobiological mechanisms but are often considered distinct disorders. Prospective, observational studies across asthma, COPD and asthma-COPD overlap are limited. NOVELTY is a global, prospective observational 3-year study enrolling ∼12 000 patients ≥12 years of age from primary and specialist clinical practices in 19 countries (ClinicalTrials.gov identifier: NCT02760329). NOVELTY's primary objectives are to describe patient characteristics, treatment patterns and disease burden over time, and to identify phenotypes and molecular endotypes associated with differential outcomes over time in patients with a diagnosis/suspected diagnosis of asthma and/or COPD. NOVELTY …

Changes In Muscle Size, Quality And Power Are Related To Physical Function In Patients With Critical Illness, Kirby Mayer

Theses and Dissertations--Rehabilitation Sciences

Patients admitted to intensive care unit (ICU) are known to develop significant impairments in physical function. Patients with critical illness suffer up to 30% reductions in muscle size within the first ten days of admission to the ICU. Muscle strength testing, Medical Research Council-sum score, is current gold-standard to diagnosis ICU-acquired weakness and predicts risk of mortality and long-term physical function. Muscle power different from muscle strength in that it accounts for velocity of movement, is potentially a better independent predictor of function that has not been studied in this population. In addition, we hypothesize that muscle size and quality …

Imaging-Based Clusters In Former Smokers Of The Copd Cohort Associate With Clinical Characteristics: The Subpopulations And Intermediate Outcome Measures In Copd Study (Spiromics), Babak Haghighi, Sanghun Choi, Jiwoong Choi, Eric A. Hoffman, Alejandro P. Comellas, John D. Newell, Chang Hyun Lee, R. Graham Barr, Eugene Bleecker, Christopher B. Cooper, David Couper, Mei Lan Han, Nadia N. Hansel, Richard E. Kanner, Ella A. Kazerooni, Eric A.C. Kleerup, Fernando J. Martinez, Wanda O'Neal, Robert Paine, Stephen I. Rennard, Benjamin M. Smith, Prescott G. Woodruff, Ching-Long Lin

Journal Articles: Pulmonary & Critical Care Med

BACKGROUND: Quantitative computed tomographic (QCT) imaging-based metrics enable to quantify smoking induced disease alterations and to identify imaging-based clusters for current smokers. We aimed to derive clinically meaningful sub-groups of former smokers using dimensional reduction and clustering methods to develop a new way of COPD phenotyping.

METHODS: An imaging-based cluster analysis was performed for 406 former smokers with a comprehensive set of imaging metrics including 75 imaging-based metrics. They consisted of structural and functional variables at 10 segmental and 5 lobar locations. The structural variables included lung shape, branching angle, airway-circularity, airway-wall-thickness, airway diameter; the functional variables included regional ventilation, …

Analgesia And Sedation Medication Use In Infants With Congenital Diaphragmatic Hernia Is Associated With Adverse Outcome, Mark Weems, Theresa Grover, Robert Digeronimo, Jason Gien, Ruth Seabrook, Sarah Keene, Natalie Rintoul, Beverly Brozanski, John Daniel, Rachel Chapman, Burhan Mahmood, Yvette Johnson, Yigit Guner, Holly Hedrick, Isabella Zaniletti, Karna Murthy

Posters

This study describes the use and variation of sedation and analgesic medications as well as short-term clinical outcomes in infants with congenital diaphragmatic hernia.