Critical Care Commons^™

Pediatric Pulmonary Artery Aneurysms Causing Pulmonary Hemorrhage: A Case Of Transcatheter Intervention While On Va Ecmo Support, Igor Areinamo

Research Days

Background: The incidence of pulmonary artery aneurysm (PAA) in children remains unknown. There are few reports of a transcutaneous interventional approach to address this type of pathology. Management of PAAs while on VA ECMO has not been described in pediatrics.

Objectives/Goal:

Methods/Design:

Case: 9-year-old previously healthy male presented with MRSA associated ARDS and sepsis requiring urgent VA ECMO cannulation. Chest CT done on ECMO day 22 showed development of right sided PAAs. Patient had an episode of significant pulmonary hemorrhage. Angiogram demonstrated two fusiform right PAAs, one of which had ruptured and was bleeding into the lung parenchyma. Patient had …

Role Of Interferon Gamma Release Assay In The Diagnosis And Management Of Mycobacterium Tuberculosis-Associated Uveitis: A Review, Samra Rahman, Muhammad Irfan, Rehman Siddiqui

Section of Pulmonary & Critical Care

Tuberculosis (TB)-associated uveitis is a common cause of infectious uveitis in the developing world. Diagnosis of TB uveitis remains a challenge. The role of interferon gamma release assays (IGRAs) is uncertain. Herein we summarise the available literature on the utility of IGRAs in the diagnosis and management of TB uveitis. We searched PubMed database from 1 August 2010 to 31 July 2020 using the following keywords alone and in combination: 'interferon-gamma release assay', 'QuantiFERON', 'T-SPOT.TB', 'TB uveitis', 'serpiginous like choroiditis', 'tuberculoma', 'TB vasculitis', 'TB panuveitis' and 'ocular tuberculosis'. Data from 58 relevant studies were collated. The review is focused on …

Local Implementation And Standardization Of The Pediatric Severe Traumatic Brain Injury Guidelines, Michelle Brown

Research Days

Problem Statement/Question: Severe pediatric Traumatic Brain Injury (TBI) remains a significant cause of morbidity and mortality. Evidence-based guidelines leave gaps in how to best implement and deliver standardized care on the local hospital level.

Background/Project Intent (Aim Statement): We aim to improve clinical outcomes for severe TBI patients (Glasgow Coma Scale ≤8) with standardization of care according to updated evidence-based guidelines. We will target early guideline adherence (initial 72 hours of PICU admission) with a focus on 1) targeted temperature management (TTM40mmHg).

Methods (include PDSA cycles): The Children’s Mercy Hospital Pediatric ICU Severe TBI Guidelines were updated after the 3rd …

C-Reactive Protein Values To Predict Sepsis-Induced Inflammatory Response In Premature Infants, Megan H. Tucker

Research Days

Background: C-reactive protein (CRP) is an inflammatory marker that has been recognized as a biomarker of the systemic inflammatory response in preterm neonates. We hypothesized that initial and peak CRP values would correlate with the degree of sepsis-induced acute lung injury (ALI) as measured by the pulmonary severity score (PSS).

Objectives/Goal: 1) Determine if confirmed (CF) sepsis events are associated with higher initial and peak CRP values than rule out (RO) sepsis events. 2) Investigate if initial and/or peak CRP correlates with severity of sepsis-induced ALI as measured by the PSS.

Methods/Design: In this retrospective case control study, we included …

Educating Providers: Timely Post-Operative Pain Management In A Level Iv Neonatal Intensive Care Unit (Nicu), Jamesia Donato, Jamesia Donato

Research Days

Background/Project Intent (Aim Statement): NICU patients often encounter painful procedures and can have significant short and long-term consequences from inadequately treated pain. Ensuring adequate pharmacological and nonpharmacological pain management while minimizing associated risks is paramount. Our NICU is part of the Children’s Hospitals Neonatal Consortium “Erase Pain” collaborative to improve management of postop pain in neonates. SMART Aim: Increase the percentage of patients receiving acetaminophen within one hour after surgery to greater than 70% by July 2020.

Methods (include PDSA cycles): A multidisciplinary team developed pain treatment algorithms and postop order plans to standardize the approach to postop pain management. …

Pulmonary Severity Score As A Measure Of Sepsis-Induced Acute Lung Injury In Preterm Infants, Megan H. Tucker

Research Days

Background: Sepsis is the most common indirect cause of acute lung injury (ALI) in adult and pediatric patients, yet no studies have described this phenomenon in preterm infants. We hypothesize that sepsis-induced ALI occurs in neonates and increases the risk of bronchopulmonary dysplasia (BPD) in preterm infants.

Objectives/Goal: 1) To investigate whether late onset sepsis (LOS) and other systemic inflammatory diseases are temporally correlated with ALI as quantified by pulmonary severity score (PSS) trajectory. 2) To determine the sepsis subtypes associated with the greatest severity of ALI.

Methods/Design: We included infants < 31 weeks gestational age and < 1500 grams with LOS in this retrospective case control study. The PSS was calculated at 72, 48, and 24 hours (hr) prior to, at the time of, and 24, 48, 72, and 168hr after sepsis diagnosis. We further defined rule out (RO) sepsis (blood culture negative; antibiotics continued only 48-72hr), blood culture positive (Cx+) sepsis, necrotizing enterocolitis (NEC), urinary tract infection (UTI), and culture negative (Cx-) clinical sepsis (blood culture negative; antibiotics continued > 6 days; specific lab criteria met). PSS trajectories for …

Utilization Of Enteral Tranexamic Acid To Stabilize Gastrointestinal Hemorrhage In Pediatric Patients On Ecmo, Gina Patel, Jenna Miller, Thomas M. Attard, Asdis Finnsdottir Wagner

Presentations

Background:

Incidence and management of Gastrointestinal (GI) bleeding on ECMO isn’t well reported Patients on ECMO require systemic anticoagulation making GI bleeding difficult to manage We describe the use of enteral tranexamic acid (TXA) in two pediatric patients with GI hemorrhage on ECMO

Utilization Of Enteral Tranexamic Acid To Stabilize Gastrointestinal Hemorrhage In Pediatric Patients On Ecmo, Gina Patel, Jenna Miller, Thomas M. Attard, Asdis Finnsdottir Wagner

Posters

Hemorrhagic and thrombotic complications on Extracorporeal Membrane Oxygenation (ECMO) support are associated with significant morbidity and mortality. There is a paucity of literature describing the incidence and management of Gastrointestinal (GI) bleeding on ECMO. We describe the use of enteral tranexamic acid (TXA) as an alternative strategy in two pediatric patients with GI hemorrhage on ECMO. Case 1 A 5-year-old with Wilms Tumor required Veno-Venous ECMO due to respiratory failure associated with pulmonary hemorrhage and air-leak syndrome. Her course was complicated by severe GI hemorrhage refractory to IV proton pump inhibitor (PPI), IV TXA and octreotide infusions. Concomitant IV TXA …

Evaluation Of An Elevated Vte Thromboprophylaxis Guideline For Critically Ill Patients Infected With Covid-19, Tony Nguyen, Heidi Clarke

All Publications

Retrospective studies and systematic-review meta-analysis have shown an association in inducing a prothrombotic state in patients infected with COVID-19. The risk of VTE are compounded in the critically ill. Current practices at Baptist Hospital of Miami (BHM) is to routinely order standard prophylactic dosed chemical thromboprophylaxis for all patients infected with COVID-19. In August 2020 an anticoagulation guidance document was approved to tailor anticoagulation dosing for critically ill COVID-19 patients. At risk patients were based on clinical and laboratory markers such as D-dimer, CRP, and ferritin. Following implementation, our analysis show a statistically significant reduction in the number of treatment …

Recalibration Of The Renal Angina Index For Pediatric Septic Shock., Natalja L. Stanski, Hector R. Wong, Rajit K. Basu, Natalie Z. Cvijanovich, Julie C. Fitzgerald, Scott L. Weiss, Michael T. Bigham, Parag N. Jain, Adam Schwarz, Riad Lutfi, Jeffrey Nowak, Geoffrey L. Allen, Neal J. Thomas, Jocelyn R. Grunwell, Michael Quasney, Bereketeab Haileselassie, Lakhmir S. Chawla, Stuart L. Goldstein

Manuscripts, Articles, Book Chapters and Other Papers

Introduction: Sepsis-associated acute kidney injury (AKI) is a common diagnosis in children that is associated with poor outcomes. The lack of therapeutic options once present makes early identification of at-risk patients essential. The renal angina index (RAI) has been previously validated to predict severe AKI in heterogeneous populations of critically ill children. The performance of this score specifically in children with septic shock is unknown.

Methods: A secondary analysis of a multicenter, prospective, observational study of 379 children with septic shock to determine the ability of the RAI to predict severe AKI at day 3, and to assess for the …

Efficacy Of Advanced Prehospital Communication In Acute Ischemic Stroke Treatment, Dylan Horinek

MSN Capstone Projects

Ischemic stroke outcomes are directly affected by time to treatment. This intervention demonstrates promise in decreasing time to treatment by optimizing pres-hospital communication, basically giving a report to providers and registration information before the patient arrives at the facility. The use of an advanced digital application has demonstrated in multiple studies significant difference in time to treatment in ischemic stroke, and ultimately leads to improved patient outcomes, increased staff satisfaction, and increased facility revenue.

Violence Against Healthcare Workers During The Covid-19 Pandemic: A Review Of Incidents From A Lower-Middle-Income Country, Omaima Anis Bhatti, Hareem Rauf, Namrah Aziz, Russell S. Martins, Javaid Khan

Medical College Documents

Background: Healthcare workers (HCWs) across the globe have met tremendous challenges during the COVID-19 (coronavirus disease 2019) pandemic, such as shortages of personal protective equipment, extensive work hours, and constant fear of catching the virus or transmitting it to loved ones. Adding on to the already existing burnout, an increase in incidents of violence and aggression against HCWs was seen in Pakistan and globally.
Objectives: Primarily to review cases of violence against HCWs in Pakistan, highlighting and comparing the instigating factors seen within the country and globally. Secondly, to enlist possible interventions to counter workplace violence in healthcare during a …

Respiratory Pathogens In Patients With Acute Exacerbation Of Non-Cystic Fibrosis Bronchiectasis From A Developing Country, Shayan Shahid, Kausar Jabeen, Nousheen Iqbal, Joveria Farooqi, Muhammad Irfan

Medical College Documents

Bronchiectasis unrelated to cystic fibrosis (non-CF bronchiectasis) has become a major respiratory disease in developing nations. The dilated mucus filled airways promote bacterial overgrowth followed by chronic infection, bronchial inflammation, lung injury and re-infection Accurate pathogen identification and antimicrobial susceptibility allowing appropriate treatment, in turn, may break this vicious cycle. To study the spectrum and antimicrobial spectrum of pathogen yielded from respiratory specimens in adult patients with acute exacerbation of non-cystic fibrosis (CF) bronchiectasis. This cross-sectional study was performed at the pulmonology clinics of the Aga Khan University, Karachi, Pakistan from 2016-2019. Respiratory specimens were collected from adult patients with …

C25: The “Spot Sign”: A Predictor Of Hematoma Expansion, Mckenzie Merritt

Annual Research Symposium

No abstract provided.

Acute Chylous Peritonitis Due To Idiopathic Pancreatitis Mimicking Acute Appendicitis, Dan Bratu, Alin Mihetiu, Dragoș Virgil Davițoiu, Vlad Dumitru Băleanu, Liliana Florina Andronache, Oana Popescu

Journal of Mind and Medical Sciences

The acute development and the accumulation of chyle into the peritoneal space is a rare condition and one needs to be able to distinguish it from chylous ascites, which is most commonly chronic and associated with related diseases. It is frequently idiopathic and additionally, clinical and imaging findings are nonspecific. In almost all cases, the diagnosis is made intraoperatively during laparoscopy or laparotomy, most diagnostic procedures being indicated by acute complaints pertaining to the abdomen. A 23-year-old man was admitted to the Emergency Department with abdominal pain, with right iliac fossa tenderness and peritonism. Laparoscopy was performed due to acute …

Support For Family Members Who Are Caregivers To Relatives With Acquired Brain Injury, Janet Walker, Lourens Schlebusch, Bernhard Gaede

Journal of Mind and Medical Sciences

Objectives. Family members caring for a patient with acquired brain injury (ABI) are coping with inordinate levels of stress partially due to their lack of understanding of the neuropsychological effects of acquired brain injury in the patient. The objective of this research is to show that as the caregivers’ stress levels increase, there is an increase in suicidal ideation. This highlights the causal relationship between unhealthy stress and reduced psychological well-being in these caregivers. In addition, qualitative research evidence regarding the caregivers’ views of their main sources of stress are presented. Methods. The participants were a random sample of 80 …

A Case Of Abdominal Compartment Syndrome In Cardiac Surgery: A Rare, Potentially Fatal Complication., Michelle Chen, K. Gage Parr

Anesthesiology and Critical Care Medicine Faculty Posters and Presentations

No abstract provided.

National Registry Of Interstitial Lung Disease From Pakistan, Ali Bin Sarwar Zubairi, Mosavir Ansarie, Talha Mahmud, Saadia Ashraf, Nisar Ahmed Rao, Arshad Javaid, Zubair Shaheen, Shereen Khan, Afzaalullah Khan

Section of Pulmonary & Critical Care

Introduction: Interstitial lung disease (ILD) is a heterogeneous group of over 200 parenchymal lung diseases with a myriad of etiologies. Interstitial lung disease registries from around the world show varying prevalence and incidence of these diseases. The aim of this study was to determine the epidemiology and characteristics of ILD in Pakistan.
Methods: This web-based registry, which is the first multicenter registry of ILD from Pakistan, recruited patients from 10 centers of five major cities between January 2016 and March 2019.
Results: A total of 744 patients were enrolled in the registry. The five most frequent ILDs were idiopathic pulmonary …

Barriers To Healthy Births At Nigerian Hospitals, Caroline Johnston

Senior Theses

Maternal mortality is a problem everywhere, but it is especially dangerous in Nigeria where the average woman experiences pregnancy six times during her lifetime (Population Reference Bureau, 2001). Many researchers focus on the medical complications associated with labor, such as hemorrhage, eclampsia, or infection. Although these birth complications are the direct sources of maternal death, it is also important to recognize how maternal mortality is a multifaceted issue influenced by local cultural groups, religions, politics, poverty level and the absence of basic infrastructures. Although maternal mortality is interconnected with social and geographical elements, my paper concentrates on Nigerian hospitals and …

Post Covid-19 Tuberculosis: An Emerging Threat Of Pandemic, Aqusa Zahid, Nousheen Iqbal, Sarosh Moeen, Muhammad Irfan

Section of Pulmonary & Critical Care

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) pandemic has hit the world hard. Millions of people have died due to the infection and several have suffered with what are now known as post COVID-19 squeal. Among these squeals one is immunosuppression which leaves patients prone to severe opportunistic infection. We here report a case of young female who was infected by COVID-19 and later developed cavitary pneumonia which upon investigation turned out to be due to mycobacterium tuberculosis. Through this report we aim to highlight the importance of high index of suspicion for infection like Mycobacterium tuberculosis after …

Overcoming Communication Barriers: An Evaluation Of Communication Devices For Healthcare Providers Wearing Powered Air-Purifying Respirators (Paprs), Trevor Hebenstreit, Geoffrey Ho, Amy Tronnier, Everett Chu, Ivy Benjenk, Paul Dangerfield, Ryan Keneally, Timothy Liu, Marian Sherman

Anesthesiology and Critical Care Medicine Faculty Posters and Presentations

No abstract provided.

Knowledge And Attitude Towards Identification And Management Of Sepsis Among Resident Physicians In A Tertiary Care Teaching Hospital In Pakistan, Ainan Arshad, Abdul Aziz, Ahmed Ayaz, Syed Maaz Salahuddin, Bushra Jamil

Section of Internal Medicine

This study was conducted to determine the compliance and knowledge of sepsis guidelines among resident physicians in a tertiary care hospital of a developing country. A self-structured validated questionnaire was prepared to evaluate compliance and knowledge of the Surviving Sepsis Campaign (SSC) guidelines. A total of 76 resident physicians completed the questionnaire; out of these, 51 (67%) were from Internal Medicine department and 25 (33%) were from Emergency Medicine department of the Aga Khan University Hospital, Karachi. A total of 71 (93%) participants claimed to be aware of the SSC guidelines but only 20 (26%) considered themselves very knowledgeable on …

Knowledge About Continuous Positive Airway Pressure Machine Usage Among Nurses At A Tertiary Hospital In Tanzania, Wilson Paulo Lomnyack, Tumbwene Mwansisya, Stewart Mbelwa, Kahabi Isangula, Zephania Saitabau Abraham

School of Nursing & Midwifery, East Africa

Introduction: Continuous Positive Airway Pressure (CPAP) provides an air pressure that maintains the patency of the airway in patients with a variety of breathing problems. Nurses provide the hour to hour management of patients who require CPAP. The aim of this study was to assess the knowledge of nurses about CPAP machine usage at the tertiary hospital in Tanzania which serves the largest number of patients who require CPAP.

Method: A hospital-based descriptive cross-sectional study was carried out from March to June 2019 at Muhimbili National Hospital (MNH) and Jakaya Kikwete Cardiac Institute (JKCI) where 149 nurses who consented …

Methamphetamine Associated Cardiomyopathy In Pregnancy: The Distinctions And The Implications, Ashan Hatharasinghe, Hossein Akhondi

HCA Healthcare Journal of Medicine

Introduction

Methamphetamine associated cardiomyopathy (MAC) and peripartum cardiomyopathy (PPCM) are both rare obstetric conditions. Literature regarding methamphetamine associated cardiomyopathy in the obstetric population is limited, and it can be difficult to make the distinction between the two given the similarities in clinical presentation. However similar, there are significant distinctions in the pathophysiology of these two that can help clinicians with the management process.

Clinical Findings and Outcomes

This case involves a 35-year-old Hispanic G6P5005 at 37 weeks gestation presenting with acute respiratory failure secondary to acute decompensated heart failure with reduced ejection fraction and superimposed preeclampsia leading to urgent cesarean …

Ionized Or Total Magnesium Levels, What Should We Measure In Critical Ill Patients?, Giuliana Scarpati, Daniela Baldassarre, Filomena Oliva, Gabriele Pascale, Ornella Piazza

Translational Medicine @ UniSa

Monitoring and measuring magnesium (Mg) values are essential to prevent the development of numerous complications in perioperative medicine and critically ill patients. Although previous studies suggest that measuring free ionized magnesium (iMg) is more useful for estimating Mg status, clinicians currently rely on measurement of total serum magnesium to determine if supplemental magnesium is needed. In this review, we analyzed the recent literature to decide whether it is better to measure ionized serum Mg or total serum Mg when assessing magnesium status, whether iMg predicts clinical outcome, and what are the difficulties in measuring serum iMg levels in intensive care …

Kl-6 Levels In Covid-19, Giuliana Scarpati

Translational Medicine @ UniSa

We present preliminary results which encourage KL‐6 evaluation as a potential biomarker for phenotyping COVID-19 patients according to disease severity.

Sarcoidosis Presenting As Fatigue And Weakness, Syed Muhammad Zubair, Naveed Haroon Rashid

Section of Pulmonary & Critical Care

Sarcoidosis is a systemic granulomatous disorder of unknown cause that occurs in both men and women of all races. It typically presents in patients after 20 years of age. Sarcoidosis most frequently involves the lung, but up to 30 percent of patients present with extra-thoracic manifestations. It can involve multiple organs to a variable extent and degree. In areas, where tuberculosis is endemic, the diagnosis of sarcoidosis may be overlooked and misdiagnosed because of clinical and radiographic resemblance. Herein, we present a case of a middle-aged man who visited multiple physicians with constitutional symptoms and was treated symptomatically but did …

Appropriate Ecmo Screening Protocols For Critically Ill Patients During Covid-19, Hudson Carter, Michael Baram, Md

Phase 1

Introduction: The use of Extracorporeal membrane oxygenation (ECMO) for COVID-19 patients has proven to have several advantages that advocate for increased use, but current screening protocols have limited its use and availability. The purpose of this study was to evaluate screening criteria for ECMO patients during COVID-19 and determine their appropriateness based on resource availability.

Methods: The population included patients referred for ECMO screening, and were stratified based upon referral outcome, survival length and patient disposition. The referring physicians were contacted to gather information regarding the referral process, the patient’s status prior to referral, and possible referral to another …

“Ecmo In A Bag”: Successful Adaptation And Implementation Of A Novel Conference Idea, Johanna I. Orrick, Debra E. Newton, Kari L. Davidson, Jenna Miller, Alyssa Stoner

Posters

INTRODUCTION: Extracorporeal Membrane Oxygenation (ECMO) is an ever-evolving technical landscape that requires an advanced level of education. At our institution, a 367-bed pediatric teaching and research facility, learners include registered nurses, registered respiratory therapists, advanced practice registered nurses, resident physicians, pediatric and neonatal intensive care physicians. A certification class followed by an advanced course covers ECMO diagnoses, complications, equipment, and management prior to providing care for ECMO patients in our institution. Educational strategies include high and low fidelity simulations, didactic learning, and clinical hours at the bedside. A desire to increase the experiential learning opportunities was identified as an ECMO …

Implementation And Sustainment Strategies For Open Visitation In The Intensive Care Unit: A Multicentre Qualitative Study, Kerry A. Milner, Suzanne Marmo, Susan A. Goncalves

Nursing Faculty Publications

Objective

Open visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership.

Research design

Qualitative approach using grounded theory.

Participants

Nurse leaders in adult intensive care units with open visitation.

Setting

Magnet® or Pathway to Excellence® designated hospitals in the United States.

Methods

Semi structured interviews were conducted with 19 nurse leaders from 15 geographically …