Critical Care Commons^™

Precision Drug Delivery For Vancomycin Efficacy And Safety In Critically Ill Patients, Alexander Flannery

Theses and Dissertations--Clinical and Translational Science

Vancomycin is the most commonly prescribed antibiotic for hospitalized patients. Despite this fact and decades of clinical use, clinicians remain challenged to meet dosing targets of this narrow therapeutic index drug as well as minimize the risks of therapy, primarily nephrotoxicity. These concerns are magnified in critically ill patients given their severity. Accordingly, in a series of five clinical studies, we sought to identify optimal methods of vancomycin administration in critically ill patients to maximize efficacy and minimize nephrotoxicity via three techniques: use of continuous versus intermittent infusion, use of first-dose pharmacokinetic calculations to guide dosing, and use of loading …

Management Of Refractory Ventricular Fibrillation With Double Sequential Defibrillation, Kaitlyn A. Brown

Capstone Showcase

Patients experiencing cardiac arrest are treated according to ACLS protocols, however current protocols lack recommendations for the treatment of refractory Ventricular Fibrillation which persists after more than 3 cycles of CPR and defibrillation. One potential intervention for these cases that is being researched is the use of simultaneous or sequential activation of two defibrillators. This literature review analyzed the results of several studies to determine if double sequential defibrillation (DSD) is a viable treatment to achieve return of spontaneous circulation (ROSC) and improved patient survival. The results of the studies were mixed with some showing positive outcomes, and others showing …

Developing An End-Of-Life Discussion Protocols, James Hawley

Rural Health Professions Projects

End of life (EOL) issues are far too often addressed reactively in Emergency Departments when patients can no longer express their wishes. This scenario can result in unwanted futile care, increased healthcare costs, and emotional hardships for family and healthcare workers. The purpose of this quality improvement project was to implement a provider-patient communication protocol that would shift advanced directive conversations proactively back into the local rural primary care setting.

Potential Perioperative Complications Due To Difference In Timing Of Systemic Heparinization During Ruptured Aneurysm Coiling, Rouzbeh Kotaki, Ameer E. Hassan, Wondwossen G. Tekle

MEDI 9331 Scholarly Activities Clinical Years

Potential Perioperative Complications Due To Differences in Timing Of Systemic Heparin Distribution During Ruptured Aneurysm Coiling

Introduction:

In general, systematic heparin anticoagulation is standard in regards to neurovascular intervention. When coiling ruptured aneurysms, many neurointerventionalists have their own protocol as to timing of systemic heparinization. There is ample research and literature reviewing the frequency of perioperative events, predictors and outcomes, as well as the efficacy in the use of anticoagulants and/or antiplatelets before, during, and after neurovascular procedures to prevent adverse outcomes. However, there currently exists a dearth of research in regards to timing of distribution of heparin intraoperatively and …

Neurally Adjusted Ventilatory Assist: Summation Of The Safety Proofs And Benefits, Landry Carneal

Williams Honors College, Honors Research Projects

Neurally Adjusted Ventilatory Assist (NAVA) is a mode of ventilation that is triggered by neither flow nor pressure but by the electrical activity of the diaphragm (Stein & Firestone, 2018, p. 227). NAVA puts ventilatory control into the hands of the patient and is often used in neonates who are more challenging to ventilate. Medical practitioners, however, are skeptical to put this mode of ventilation into practice with fear that neonates are neither strong enough nor capable to manage their own respiratory efforts without hypoventilation or damage to the lungs (Lubarsky et al., 2020, p. 3). Research shows that despite …

Effectiveness Of Point-Of-Care Ultrasound Education For Advanced Practice Providers, Nicole Brumfield

DNP Projects

Abstract

Background: Provider shortages and demands for inpatient providers have led to an increase in the utilization of Advanced Practice Providers (APPs). The increased use and specialization of APPs has brought attention to education and skills that have been instituted for other provider types but remains missing from the APP curricula. One such example is point-of-care ultrasound (POCUS) education. This technology and skill set have been shown to enhance clinical skills, confidence levels, and provide useful information for the provider to enhance clinical decision making for the patient.

Purpose: The purpose of this project was to evaluate the effectiveness of …

Optimizing A Pediatric Dka Protocol In A Tertiary Care Hospital System In Northern West Virginia, Jennifer L. Burky

Graduate Theses, Dissertations, and Problem Reports (ETD)

Background: Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body compensates for insufficient insulin, producing dangerously high levels of ketones. Without proper treatment, DKA can be fatal. For that reason, staff in the pediatric intensive care unit (PICU) at a tertiary care hospital in northern West Virginia expressed concerns about the complexity of and lack of adherence to a poorly referenced and dated DKA treatment protocol.

Objective: The purpose of this project was to assess the feasibility and sustainability of optimizing the DKA protocol in the PICU. The primary objective was to implement an updated, …

Why End-Of-Life Discussion Matters: A Systematic Literature Review, Emily Grandson

All Graduate Theses, Dissertations, and Other Capstone Projects

End-of-life (EOL) discussions are a challenging yet vital topic of conversation in intensive care units (ICU) between healthcare providers, patients, and their families. There is great disparity in where, when, and how EOL discussions take place, but the consequences of neglecting their importance can be devastating physically, psychologically, and financially for all parties involved. Multiple inadequacies in the EOL discussion process have not only contributed to a personal and societal financial burden but an unacceptable quality of death for many ICU patients. A literature review was performed to determine what practice and policy changes could be made to improve EOL …

Does Team Leader Gender Matter? A Bayesian Reconciliation Of Leadership And Patient Care During Trauma Resuscitations, Elizabeth D. Rosenman, Anthony Misisco, Jeffrey Olenick, Sarah M. Brolliar, Anne K. Chipman, Marie C. Vrablik, Georgia T. Chao, Steve W.J. Kozlowski, James A. Grand, Rosemarie Fernandez

Psychology Faculty Publications

OBJECTIVE: Team leadership facilitates teamwork and is important to patient care. It is unknown whether physician gender-based differences in team leadership exist. The objective of this study was to assess and compare team leadership and patient care in trauma resuscitations led by male and female physicians.

METHODS: We performed a secondary analysis of data from a larger randomized controlled trial using video recordings of emergency department trauma resuscitations at a Level 1 trauma center from April 2016 to December 2017. Subjects included emergency medicine and surgery residents functioning as trauma team leaders. Eligible resuscitations included adult patients meeting institutional trauma …

A New Aortic Arch Dissection Classification: The Fuwai Classification, Juntao Qiu, Xinjin Luo, Jinlin Wu, Wei Pan, Qian Chang, Xiangyang Qian, Xiaogang Sun, Bo Wei, Liang Zhang, Shen Liu, Wenxiang Jiang, Cuntao Yu

Faculty, Staff and Students Publications

Aims: We describe a new aortic arch dissection (AcD) classification, which we have called the Fuwai classification. We then compare the clinical characteristics and long-term prognoses of different classifications.

Methods: All AcD patients who underwent surgical procedures at Fuwai Hospital from 2010 to 2015 were included in the study. AcD procedures are divided into three types: Fuwai type Cp, Ct, and Cd. Type Cp is defined as the innominate artery or combined with the left carotid artery involved. Type Cd is defined as the left subclavian artery or combined with the left carotid artery involved. All other AcD surgeries are …

Mitral Valve Repair Complicated By Left Circumflex Coronary Artery Occlusion: The Vital Role Of The Anesthesiologist, Andres Bacigalupo Landa, Jason Hoyos, Jayanand D'Mello

Faculty, Staff and Students Publications

The anatomical relationship between the mitral valve and the left circumflex coronary artery places this vessel at risk for occlusion during mitral valve repair or replacement. In view of the potential high morbidity and mortality of this complication, the anesthesiologist has a vital role in its prompt diagnosis. We present the case of a 47-year-old man who underwent a minimally invasive mitral valve repair, which was complicated by left circumflex coronary artery occlusion.

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.

Sarcoidosis Presenting As Vocal Cord Palsy: An Unusual Presentation And Literature Review, Mohummad Hassan Raza Raja, Muhammad Abdullah Javed, Ali Bin Sarwar Zubairi

Medical College Documents

We report the case of a 60-year-old woman, presenting with left vocal cord paralysis (VCP). Diagnostic evaluation revealed sarcoidosis to be the underlying pathology. Computed tomography (CT) scans exhibited enlarged subcarinal, pretracheal, and prevascular lymph nodes as the possible mechanism of left VCP through compression of the left recurrent laryngeal nerve. Initial treatment with oral prednisolone and azathioprine led to remission of symptoms; however, tapering of dosage led to relapse of cough without any signs of VCP. The dosage of prednisolone was further boosted, leading to complete remission. A review of literature reveals 20 cases have been reported to date, …

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.

Performance Of Lung Ultrasound In The Diagnosis Of Pediatric Pneumonia In Mozambique And Pakistan, Amy Sarah Ginsburg, Jennifer L. Lenahan, Fyezah Jehan, Rubao Bila, Alessandro Lamorte, Jun Hwang, Lola Madrid, Muhammad Imran Nisar, Benazir Baloch, Naila Nadeem

Department of Paediatrics and Child Health

Introduction: Improved pneumonia diagnostics are needed in low-resource settings (LRS); lung ultrasound (LUS) is a promising diagnostic technology for pneumonia. The objective was to compare LUS versus chest radiograph (CXR), and among LUS interpreters, to compare expert versus limited training with respect to interrater reliability.
Methods: We conducted a prospective, observational study among children with World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) chest-indrawing pneumonia at two district hospitals in Mozambique and Pakistan, and assessed LUS and CXR examinations. The primary endpoint was interrater reliability between LUS and CXR interpreters for pneumonia diagnosis among children with WHO IMCI …

Randomised Controlled Trial To Assess The Effectiveness Of Apnoeic Oxygenation In Adults Using Low-Flow Or High-Flow Nasal Cannula With Head Side Elevation Versus Usual Care To Prevent Desaturation During Endotracheal Intubation In The Emergency Department (Apoxed): Study Protocol, Shahan Waheed, Nazir Najeeb Kapadia, Muhammad Faisal Khan, Salima Mansoor Kerai, Ahmed Raheem, Rubaba Naeem

Department of Emergency Medicine

Introduction: Apnoeic oxygenation is a process of delivering continuous oxygen through nasal cannula during direct laryngoscopy. The oxygen that is delivered through these nasal cannulas is either low flow or high flow. Although the effectiveness of apnoeic oxygenation has been shown through systematic reviews and randomised controlled trials, a comparison of high-flow versus low-flow oxygen delivery has not been tested through a superiority study design. In this study we propose to assess the effectiveness of giving low-flow oxygen with head side elevation versus high-flow oxygen with head side elevation against the usual practice of care in which no oxygen is …

Lung Nodule In A Patient With Multiple Myeloma, William C Harding, Mathieu Marcoux, Roberto F Casal, Lara Bashoura, John Stewart, Hans C Lee, Saadia A Faiz

Faculty, Staff and Student Publications

No abstract provided.

Risk Factors For Intensive Care Unit Admission And Mortality In Hospitalized Covid-19 Patients, Ahmed Ayaz, Ainan Arshad, Hajra Malik, Haris Ali, Erfan Hussain, Bushra Jamil

Medical College Documents

Background: This study investigated the clinical features and outcome of hospitalized coronavirus disease 2019 (COVID-19) patients admitted to our quaternary care hospital.
Methods: In this retrospective cohort study, we included all adult patients with COVID-19 infection admitted to a quaternary care hospital in Pakistan from March 1 to April 15, 2020. The extracted variables included demographics, comorbidities, presenting symptoms, laboratory tests and radiological findings during admission. Outcome measures included in-hospital mortality and length of stay.
Results: Sixty-six COVID-19 patients were hospitalized during the study period. Sixty-one percent were male and 39% female; mean age was 50.6±19.1 years. Fever and cough …

Family Presence During Resuscitation, Brittany Whistle

Scholars Week

Background:

Families want more involvement in their loved one’s care than they did just twenty years ago. Especially, in the matter of resuscitation efforts, this involvement remains controversial.

Evidence and Findings:

Based on research, theories, and multiple educated opinions, family presence during resuscitation (FPDR) needs to be implemented in hospitals. Theories by Kolcaba and Helvie demonstrate a need for comfort and positive energy around patients to enhance the healing process. Evidence has shown multiple benefits of FPDR. The patient receives a holistic approach of care, the family gains closure and feeling of participation of care, and provides a plan for …

Acute Skeletal Muscle Wasting And Dysfunction Predict Physical Disability At Hospital Discharge In Patients With Critical Illness, Kirby P. Mayer, Melissa L. Thompson Bastin, Ashley A. Montgomery-Yates, Amy M. Pastva, Esther E. Dupont-Versteegden, Selina M. Parry, Peter E. Morris

Physical Therapy Faculty Publications

BACKGROUND: Patients surviving critical illness develop muscle weakness and impairments in physical function; however, the relationship between early skeletal muscle alterations and physical function at hospital discharge remains unclear. The primary purpose of this study was to determine whether changes in muscle size, strength and power assessed in the intensive care unit (ICU) predict physical function at hospital discharge.

METHODS: Study design is a single-center, prospective, observational study in patients admitted to the medicine or cardiothoracic ICU with diagnosis of sepsis or acute respiratory failure. Rectus femoris (RF) and tibialis anterior (TA) muscle ultrasound images were obtained day one of …

Tough Decisions During The Covid 19 Pandemic: A Frail Latino Patient, Irma Huayanay, Stephanie Luu

School of Medicine Publications

The pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had overwhelmed the healthcare system worldwide with multiple ethical dilemmas. Several tools have been used to assess risk factors in these patients. One of them, the Clinical Frailty scale, has shown good correlation between the patient functional status and hospital stay with overall mortality. We present a case were the Clinical Frailty Scale was used to assess patient management and goals of care.

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 …

Decluttering, Carolina Ciacci, Ornella Piazza

Translational Medicine @ UniSa

our point of view on the COVID-19 pandemic in a confessional style.

Saving Limited Resources During Covid-19 Pandemic, Ornella Piazza

Translational Medicine @ UniSa

An epidemic is not only a disease but a social crisis.

Accuracy Of Rn Visual Quantification Of Emesis Volumes In The Neonatal Intensive Care Unit, Stephen Stoever

Seton Hall University DNP Final Projects

An important component of nursing assessment of feeding tolerance in the neonatal intensive care unit (NICU) for both low-risk and high-risk babies, is the quantification of emesis volumes. While some nurses attempt to weigh the items saturated in emesis in order to quantify volume loss (QEV), there is no or limited consistency in this practice across nurses in this unit. Rather, volumes are “best-guessed” or estimated (EEV) and reported to the practitioner for decision-making. Often feed advances are paused or limited due to perceived feeding intolerance connected to emesis events in neonates.

For this project, 158 NICU nurses at a …

Transcutaneous Energy Transmission: Can We Do It Now?, Yuriy Pya

The VAD Journal

The percutaneous driveline used in contemporary LVADs presents a continuous risk of infection for the duration of support. Minimizing infection in durable mechanical circulatory support systems requires total implantation of all components and energy transfer by means other than percutaneous drivelines. A novel coplanar energy transfer (CET) system, similar to the original transcutaneous energy transfer (TET) design, is unique by incorporating two large rings with coil-within-the-coil topology to ensure strong resonance power. The CET system consists of an internal integrated controller, a battery coupled with an internal thoracic coil ring, and the LVAD pump. External equipment includes a power transmission …

Physical Activity After Delivery: A Feasibility Study, Antonio Gonzalez Fiol, Md, Geoffrey Ho, Mbbs, Dongchen Li, Md, Richard Amdur, Phd, Chapman Wei, Md, Homa K. Ahmadzia, Md, Marianne David, Md, Christopher Jackson, Md, Jeffrey S. Berger, Md, Mba

Anesthesiology and Critical Care Medicine Faculty Publications

Background: Early mobility is one of the main goals of the enhanced recovery after cesarean delivery, yet it is rarely objectively measured. Benefits related to this goal include mechanical prevention of deep venous thrombosis and early discharge.

Methods: We conducted a multi-center prospective study in which an activity tracker was utilized to measure the steps taken by patients after delivery. The primary outcome was steps taken after vaginal or cesarean delivery. Secondary outcomes was factors affecting ambulation (e.g pain/satisfaction with pain management and mode of delivery).

Results: Data from 50 postpartum patients were analyzed. Vaginal delivery patients took more cumulative …

Irrigation For Cerumen Removal Causing Meningitis – Case Report, Steven Tenny, Pashayar Lookian, Andre Wakim, Daniel Surdell

Graduate Medical Education Research Journal

Introduction: Cerumen impaction is a common problem seen in primary care clinics. There are a variety of methods to deal with impacted cerumen including water irrigation but meningitis after water irrigation cerumen removal has not been previously reported.

Methods: We describe the case of a 59-year-old female with otitis media who developed meningitis with empyema after water-jet irrigation for impacted cerumen.

Results: Our patient presented 24-hours after water-jet irrigation for impacted cerumen with worsening headaches. Workup included positive CSF cultures and empyema on MRI consistent with meningitis. She also had ear drainage from the treated ear which was positive for …