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Sharma M, Jagirdhar GSK, Guntupalli KK, Kashyap R, Surani S. Heart failure in general and cardiac transplant patients with COVID-19. World J Cardiol 2022; 14:392-402. [PMID: 36161057 PMCID: PMC9350602 DOI: 10.4330/wjc.v14.i7.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/19/2022] [Accepted: 06/27/2022] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is primarily an infection of the respiratory tract, but it can have multisystem manifestations. Cardiac complications of COVID-19 can range from acute myocardial injury, cardiac arrhythmias, or heart failure, amongst others. Heart failure (HF) in COVID-19 can be a de novo process or due to worsening of pre-existing cardiovascular ailment. HF in a patient with COVID-19 not only poses challenges in clinical presentation and management of COVID-19 but also affect prognosis of the patient. This article aims to succinctly revisit the implications of this pandemic regarding pre-existing HF or new-onset HF based on prevailing data. It also focuses on the management and special recommendations from prior studies and guidelines.
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Hughes CG, Mailloux PT, Devlin JW, Swan JT, Sanders RD, Anzueto A, Jackson JC, Hoskins AS, Pun BT, Orun OM, Raman R, Stollings JL, Kiehl AL, Duprey MS, Bui LN, O'Neal HR, Snyder A, Gropper MA, Guntupalli KK, Stashenko GJ, Patel MB, Brummel NE, Girard TD, Dittus RS, Bernard GR, Ely EW, Pandharipande PP. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med 2021; 384:1424-1436. [PMID: 33528922 PMCID: PMC8162695 DOI: 10.1056/nejmoa2024922] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Guidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown. METHODS In a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 μg per kilogram of body weight per hour) or propofol (5 to 50 μg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation-Sedation Scale (RASS, on which scores range from -5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months. RESULTS Of 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses - 214 patients received dexmedetomidine at a median dose of 0.27 μg per kilogram per hour, and 208 received propofol at a median dose of 10.21 μg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was -2.0 (interquartile range, -3.0 to -1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups. CONCLUSIONS Among mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01739933.).
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Rali AS, Nunna KR, Howard C, Herlihy JP, Guntupalli KK. High-flow Nasal Cannula Oxygenation Revisited in COVID-19. Card Fail Rev 2020; 6:e08. [PMID: 32377387 PMCID: PMC7199186 DOI: 10.15420/cfr.2020.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Kapoor S, Morgan CK, Siddique MA, Guntupalli KK. Intensive care unit complications and outcomes of adult patients with hemophagocytic lymphohistiocytosis: A retrospective study of 16 cases. World J Crit Care Med 2018; 7:73-83. [PMID: 30596029 PMCID: PMC6305525 DOI: 10.5492/wjccm.v7.i6.73] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/21/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis (HLH) in the intensive care unit (ICU).
METHODS We performed a retrospective observational study of adult patients with the diagnosis of “HLH” admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society.
RESULTS Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years. Median age of presentation was 49 years and 10 (63%) were males. Median Sequential Organ Failure Assessment (SOFA) score at the time of ICU admission was 10. Median ICU length of stay (LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in (88%) patients, followed by acute kidney injury (81%) and acute respiratory failure requiring mechanical ventilation (75%). Nine patients (56%) developed disseminated intravascular coagulation and eight (50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed. Multi system organ failure was the most common cause of death seen in 12 (75%) patients. The 30 d mortality was 37% (6 cases) and 90 d mortality was 81% (13 cases). There was no difference in mortality based on age (above or less than 50 years), SOFA score on ICU admission (more than or less than 10), immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer.
CONCLUSION HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.
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Kapoor S, Morgan CK, Siddique MA, Guntupalli KK. "Sacred Pause" in the ICU: Evaluation of a Ritual and Intervention to Lower Distress and Burnout. Am J Hosp Palliat Care 2018; 35:1337-1341. [PMID: 29618221 DOI: 10.1177/1049909118768247] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Increased exposure to deaths in the intensive care unit (ICU) generate grief among ICU staff, which remains unresolved most of the time. Unresolved grief becomes cumulative and presents a risk factor for burnout. "sacred pause" is a ritual performed at patient's death to honor the lost life and recognize the efforts of the health-care team. OBJECTIVE To study the impact of the ritual of sacred pause on the attitudes and behaviors of the ICU physicians and nurses. METHODS Ten-question online anonymous survey was sent to ICU physicians and nurses in the medical ICU of a tertiary care hospital in July 2017. RESULTS Thirty-four ICU team members completed the survey including 12 physicians and 22 nurses. Seventy sacred pause rituals were performed from July 2016 to June 2017. Seventy-nine percent respondents believed that the ritual brought closure and helped them overcome the feelings of disappointment, grief, distress, and failure after the death of their patient in ICU. Seventy-three percent agreed that the ritual has instilled and encouraged a sense of team effort. Eighty-two percent responded that the ritual makes their efforts feel appreciated. Many felt that the ritual should be a universal phenomenon in all ICUs. Only 55% respondents felt that the practice has a potential to decrease ICU burnout, many of them (42%) were undecided. CONCLUSION Sacred pause brings closure, prevents cumulative grief and distress, builds resilience, promotes team effort, and improves professional satisfaction of ICU team. It may lower burnout syndrome in ICU, but further studies are warranted.
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Abstract
Preview There is considerable overlap in features and treatment of chronic obstructive pulmonary disease and asthma. Why, then, is it necessary to distinguish between the two? As the authors explain, the two diseases have different causes, risk factors, and clinical courses. Correct diagnosis, described in this article, allows physicians to take measures that reduce exacerbations and to accurately assess progress.
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Kaminsky DA, Guntupalli KK, Lippmann J, Burns SM, Brock MA, Skelly J, DeSarno M, Pecott-Grimm H, Mohsin A, LaRock-McMahon C, Warren P, Whitney MC, Hanania NA. Effect of Yoga Breathing (Pranayama) on Exercise Tolerance in Patients with Chronic Obstructive Pulmonary Disease: A Randomized, Controlled Trial. J Altern Complement Med 2017; 23:696-704. [PMID: 28714735 DOI: 10.1089/acm.2017.0102] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Pulmonary rehabilitation improves exercise tolerance in patients with chronic obstructive pulmonary disease (COPD). However, many patients do not have access to pulmonary rehabilitation programs. We hypothesized that an alternative to pulmonary rehabilitation to improve exercise tolerance is the practice of pranayama, or yoga breathing, which could be done independently at home. We also sought to determine whether yoga nonprofessionals could adequately teach pranayama to patients. DESIGN Proof-of-concept, randomized, double-blind, controlled pilot trial. SETTINGS/LOCATION Two academic pulmonary practices. SUBJECTS Forty-three patients with symptomatic, moderate-to-severe COPD. INTERVENTIONS Twelve weeks of pranayama plus education versus education alone. Two yoga professionals trained the research coordinators to conduct all pranayama teaching and monitored the quality of the teaching and the practice of pranayama by study participants. OUTCOME MEASURES The primary outcome was a change in the 6-min walk distance (6MWD). Secondary outcomes included changes in lung function, markers of oxidative stress and systemic inflammation, and measures of dyspnea and quality of life. RESULTS The 6MWD increased in the pranayama group (least square mean [95% confidence interval] = 28 m [-5 to 61]) and decreased in the control group (-15 m [-47 to 16]), with a nearly significant treatment effect (p = 0.06) in favor of pranayama. Pranayama also resulted in small improvements in inspiratory capacity and air trapping. Both groups had significant improvements in various measures of symptoms, but no overall differences in respiratory system impedance or markers of oxidative stress or systemic inflammation. CONCLUSION This pilot study successfully demonstrated that pranayama was associated with improved exercise tolerance in patients with COPD. Lay personnel were able to adequately teach patients to practice pranayama. These results suggest that pranayama may have significant clinical benefits for symptomatic patients with COPD, a concept that needs to be confirmed in future, larger clinical trials.
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Narendra DK, Hess DR, Sessler CN, Belete HM, Guntupalli KK, Khusid F, Carpati CM, Astiz ME, Raoof S. Update in Management of Severe Hypoxemic Respiratory Failure. Chest 2017; 152:867-879. [PMID: 28716645 DOI: 10.1016/j.chest.2017.06.039] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 06/17/2017] [Accepted: 06/25/2017] [Indexed: 02/07/2023] Open
Abstract
Mortality related to severe-moderate and severe ARDS remains high. We searched the literature to update this topic. We defined severe hypoxemic respiratory failure as Pao2/Fio2 < 150 mm Hg (ie, severe-moderate and severe ARDS). For these patients, we support setting the ventilator to a tidal volume of 4 to 8 mL/kg predicted body weight (PBW), with plateau pressure (Pplat) ≤ 30 cm H2O, and initial positive end-expiratory pressure (PEEP) of 10 to 12 cm H2O. To promote alveolar recruitment, we propose increasing PEEP in increments of 2 to 3 cm provided that Pplat remains ≤ 30 cm H2O and driving pressure does not increase. A fluid-restricted strategy is recommended, and nonrespiratory causes of hypoxemia should be considered. For patients who remain hypoxemic after PEEP optimization, neuromuscular blockade and prone positioning should be considered. Profound refractory hypoxemia (Pao2/Fio2 < 80 mm Hg) after PEEP titration is an indication to consider extracorporeal life support. This may necessitate early transfer to a center with expertise in these techniques. Inhaled vasodilators and nontraditional ventilator modes may improve oxygenation, but evidence for improved outcomes is weak.
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Mohan A, Naik GS, Harikrishna J, Kumar DP, Rao MH, Sarma K, Guntupalli KK. Cleistanthus collinus poisoning: experience at a medical intensive care unit in a tertiary care hospital in south India. Indian J Med Res 2017; 143:793-797. [PMID: 27748304 PMCID: PMC5094119 DOI: 10.4103/0971-5916.192068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND & OBJECTIVES Ingestion of Cleistanthus collinus causes hypokalemia and cardiac arrhythmias leading to mortality in most cases. We undertook this retrospective study to evaluate the clinical presentation and predictors of outcome in critically ill patients admitted with C. collinus poisoning. METHODS The case records of 56 patients admitted to the medical intensive care unit (MICU) of a tertiary care teaching hospital in south India (2000-2014) with C. collinus poisoning were retrospectively analysed. RESULTS The mean age of patients was 36.7±13.3 yr; there were 30 males. Salient clinical manifestations included hypokalemia (58%), neutrophilic leucocytosis (48.2%), acute kidney injury (AKI) (42.9%), acute respiratory failure requiring mechanical ventilation (AcRFMv) (32.1%), shock (21.4%); cardiac arrhythmias and neuromuscular weakness (19.6% each); 21 patients (37.5%) had adverse outcome. Longer time-lapsed from consumption to reaching emergency room [median (interquartile range)] (hours) [49 (22-97) vs. 28 (7-56), p =0.0380 ]; higher acute physiology and chronic health evaluation II (APACHE II) score at presentation [14 (8.25-14.75) vs. 2 (0-6) P<0.001]; and presence of the following [odds ratio (95% confidence intervals)] at initial presentation: shock [37.40 (4.29-325.98), P=0.001]; AcRFMv [26.67 (5.86-121.39), P<0.001]; elevated alanine aminotransferase [5.71 (1.30-25.03), p0 =0.021]; metabolic acidosis [5.48 (1.68-17.89), P=0.005]; acute kidney injury (AKI) [5 (1.55-16.06), P=0.007]; hyponatremia [4.67 (1.25-17.44), P=0.022]; and neutrophilic leucocytosis [3.80 (1.02-14.21), P=0.047] predicted death. A significant (P<0.001) increasing trend in mortality was observed with increasing International Program on Chemical Safety Poisoning Severity Score (IPCS-CSS) grade. INTERPRETATION & CONCLUSIONS C. collinus is a lethal poison associated with high mortality for which there is no specific antidote. Careful search and meticulous monitoring of the predictors of death and initiating appropriate corrective measures can be life saving.
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Guntupalli KK, Karnad DR, Bandi V, Hall N, Belfort M. Critical Illness in Pregnancy: Part II: Common Medical Conditions Complicating Pregnancy and Puerperium. Chest 2016; 148:1333-1345. [PMID: 26020727 DOI: 10.1378/chest.14-2365] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The first of this two-part series on critical illness in pregnancy dealt with obstetric disorders. In Part II, medical conditions that commonly affect pregnant women or worsen during pregnancy are discussed. ARDS occurs more frequently in pregnancy. Strategies commonly used in nonpregnant patients, including permissive hypercapnia, limits for plateau pressure, and prone positioning, may not be acceptable, especially in late pregnancy. Genital tract infections unique to pregnancy include chorioamnionitis, group A streptococcal infection causing toxic shock syndrome, and polymicrobial infection with streptococci, staphylococci, and Clostridium perfringens causing necrotizing vulvitis or fasciitis. Pregnancy predisposes to VTE; D-dimer levels have low specificity in pregnancy. A ventilation-perfusion scan is preferred over CT pulmonary angiography in some situations to reduce radiation to the mother's breasts. Low-molecular-weight or unfractionated heparins form the mainstay of treatment; vitamin K antagonists, oral factor Xa inhibitors, and direct thrombin inhibitors are not recommended in pregnancy. The physiologic hyperdynamic circulation in pregnancy worsens many cardiovascular disorders. It increases risk of pulmonary edema or arrhythmias in mitral stenosis, heart failure in pulmonary hypertension or aortic stenosis, aortic dissection in Marfan syndrome, or valve thrombosis in mechanical heart valves. Common neurologic problems in pregnancy include seizures, altered mental status, visual symptoms, and strokes. Other common conditions discussed are aspiration of gastric contents, OSA, thyroid disorders, diabetic ketoacidosis, and cardiopulmonary arrest in pregnancy. Studies confined to pregnant women are available for only a few of these conditions. We have, therefore, reviewed pregnancy-specific adjustments in the management of these disorders.
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Guntupalli KK, Hall N, Karnad DR, Bandi V, Belfort M. Critical Illness in Pregnancy. Chest 2015; 148:1093-1104. [DOI: 10.1378/chest.14-1998] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Antony KM, Agrawal A, Arndt ME, Murphy AM, Alapat PM, Guntupalli KK, Aagaard KM. Obstructive sleep apnea in pregnancy: reliability of prevalence and prediction estimates. J Perinatol 2014; 34:587-93. [PMID: 24674980 PMCID: PMC4117820 DOI: 10.1038/jp.2014.48] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 02/18/2014] [Accepted: 02/19/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We sought to ascertain the validity of two screening scales for obstructive sleep apnea (OSA) in pregnancy and to establish the prevalence of OSA in pregnancy. STUDY DESIGN In this prospective observational study, two screening scales were administered. Screen positive subjects were referred for diagnostic polysomnography (PSG); if admitted for antepartum care, screen positive subjects underwent a modified study with a type 3 device (T3D). RESULT A total of 1509 subjects underwent OSA screening; 58 completed diagnostic testing. Neither measure was a reliable diagnostic tool for OSA as determined by T3D or PSG (detection rates of 10.3% and 18.0%, respectively). Among screen positive subjects undergoing PSG or T3D testing, 15.5% ultimately met 'gold standard' OSA diagnostic criteria for an estimated point prevalence of 4.9%. CONCLUSION In this prospective trial, screening positive on the Berlin questionnaire or Epworth sleepiness scale was poorly predictive of OSA among gravidae and was associated with a high false referral rate.
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Howard CM, Kass JS, Bandi VD, Guntupalli KK. Challenges in Providing Critical Care for Patients With Anti-N-Methyl-d-Aspartate Receptor Encephalitis. Chest 2014; 145:1143-1147. [DOI: 10.1378/chest.13-1490] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Guntupalli KK, Wachtel S, Mallampalli A, Surani S. Burnout in the intensive care unit professionals. Indian J Crit Care Med 2014; 18:139-43. [PMID: 24701063 PMCID: PMC3963196 DOI: 10.4103/0972-5229.128703] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Professional burnout has been widely explored in health care. We conducted this study in our hospital intensive care unit (ICU) in United States to explore the burnout among nurses and respiratory therapists (RT). MATERIALS AND METHODS A survey consisting of two parts was used to assess burnout. Part 1 addressed the demographic information and work hours. Part 2 addressed the Maslach Burnout Inventory-Human Service Survey. RESULTS The analysis included 213 total subjects; Nurses 151 (71%) and RT 62 (29%). On the emotional exhaustion (EE) scale, 54% scored "Moderate" to "High" and 40% scored "Moderate" to "High" on the depersonalization (DP) scale. Notably 40.6% scored "Low" on personal accomplishment (PA) scale. CONCLUSION High level of EE, DP and lower PAs were seen among two groups of health care providers in the ICUs.
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Tonelli MR, Curtis JR, Guntupalli KK, Rubenfeld GD, Arroliga AC, Brochard L, Douglas IS, Gutterman DD, Hall JR, Kavanagh BP, Mancebo J, Misak CJ, Simpson SQ, Slutsky AS, Suffredini AF, Thompson BT, Ware LB, Wheeler AP, Levy MM. An Official Multi-Society Statement: The Role of Clinical Research Results in the Practice of Critical Care Medicine. Am J Respir Crit Care Med 2012; 185:1117-24. [DOI: 10.1164/rccm.201204-0638st] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Kulkarni HS, Kulkarni KR, Mallampalli A, Parkar SR, Karnad DR, Guntupalli KK. Comparison of anxiety, depression, and post-traumatic stress symptoms in relatives of ICU patients in an American and an Indian public hospital. Indian J Crit Care Med 2011; 15:147-56. [PMID: 22013306 PMCID: PMC3190465 DOI: 10.4103/0972-5229.84891] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Context: An intensive care unit (ICU) admission of a patient causes considerable stress among relatives. Whether this impact differs among populations with differing sociocultural factors is unknown. Aims: The aim was to compare the psychological impact of an ICU admission on relatives of patients in an American and Indian public hospital. Settings and Design: A cross-sectional study was carried out in ICUs of two tertiary care hospitals, one each in major metropolitan cities in the USA and India. Materials and Methods: A total of 90 relatives visiting patients were verbally administered a questionnaire between 48 hours and 72 hours of ICU admission that included the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory-II (BDI-II) and Impact of Events Scale-Revised (IES-R) for post-traumatic stress response. Statistical Analysis: Statistical analysis was done using the Mann-Whitney and chi-square tests. Results: Relatives in the Indian ICU had more anxiety symptoms (median HADS-A score 11 [inter-quartile range 9-13] vs. 4 [1.5-6] in the American cohort; P<0.0001), more depression symptoms (BDI-II score 14 [8.5-19] vs. 6 [1.5-10.5], P<0.0001) but a comparable post-traumatic stress response (IES-R score>30). 55% of all relatives had an incongruous perception regarding “change in the patient's condition” compared to the objective change in severity of illness. “Change in worry” was incongruous compared to the perception of improvement of the patient's condition in 78% of relatives. Conclusions: Relatives of patients in the Indian ICU had greater anxiety and depression symptoms compared to those in the American cohort, and had significant differences in factors that may be associated with this psychological impact. Both groups showed substantial discordance between the perceived and objective change in severity of illness.
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Antony KM, Agrawal A, Arndt ME, Murphy AM, Alapat PM, Guntupalli KK, Aagaard KM. Obstructive sleep apnea screening in pregnancy, perinatal outcomes, and impact of maternal obesity. Am J Perinatol 2011; 28:651-8. [PMID: 21480159 PMCID: PMC3966067 DOI: 10.1055/s-0031-1276740] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We employed accepted, validated symptom-based screening measures to discern attributable risk of obstructive sleep apnea (OSA) to adverse pregnancy outcomes, taking into account potential maternal confounders. Commonly employed OSA screening measures (Berlin and Epworth scales) were performed in the second and third trimesters; maternal and neonatal outcome data were thereafter obtained. The relationship between OSA and outcomes of interest were explored in stratified and multivariate models controlling for potential confounders. The overall prevalence of OSA was 25.4%. Given a nonlinear increase by body mass index (BMI) strata (8.9%, 46%; p < 0.0001), stratified multivariate analysis was subsequently performed. Among nonobese (BMI <30) gravidae, frequency of preeclampsia was significantly higher among women with OSA (adjusted odds ratio = 6.58, 95% confidence interval = 1.04, 38.51; p = 0.035). Among the obese (BMI ≥30) gravidae, infant birth weight ratio (or birth weight by gestational age) was higher with OSA + screening than OSA - (1.099 versus 1.035; p = 0.04), and this association remained significant after adjustment for potential confounders (p = 0.05). OSA prevalence increases significantly among obese gravidae, raising concerns for the overall validity of commonly employed screening measures in pregnancy. Nevertheless, OSA status continues to exert an independent influence, as obese and nonobese gravidae are at increased risk for a limited number of adverse perinatal outcomes in multivariate models.
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Guntupalli KK, Gutterman D, Raoof S, Markowski PA. Pulmonary Diseases: Response. Chest 2011. [DOI: 10.1378/chest.11-0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Munnur U, Bandi V, Guntupalli KK. Management principles of the critically ill obstetric patient. Clin Chest Med 2011; 32:53-60. [PMID: 21277449 DOI: 10.1016/j.ccm.2010.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The goals in management of critically ill obstetric patients involve intensive monitoring and physiologic support for patients with life-threatening but potentially reversible conditions. Management principles of the mother should also take the fetus and gestational age into consideration. The most common reasons for intensive care admissions (ICU) in the United States and United Kingdom are hypertensive disorders, sepsis, and hemorrhage. The critically ill obstetric patient poses several challenges to the clinicians involved in her care, because of the anatomic and physiologic changes that take place during pregnancy.
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Morris PE, Promes JT, Guntupalli KK, Wright PE, Arons MM. A multi-center, randomized, double-blind, parallel, placebo-controlled trial to evaluate the efficacy, safety, and pharmacokinetics of intravenous ibuprofen for the treatment of fever in critically ill and non-critically ill adults. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R125. [PMID: 20591173 PMCID: PMC2911773 DOI: 10.1186/cc9089] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 03/14/2010] [Accepted: 06/30/2010] [Indexed: 11/10/2022]
Abstract
Introduction Hospitalized patients are often unable to ingest or tolerate oral antipyretics and recently an aqueous formulation of intravenous (IV) ibuprofen was approved by the US-FDA for the reduction of fever in adults. Methods We evaluated IV ibuprofen to reduce fever exceeding 101.0°F, measured as the percentage of subjects achieving a temperature <101.0°F at four hours after a single dose of IV ibuprofen vs. placebo. Secondary evaluations included the effect on temperature at 24 hours. Nine sites randomized patients to receive either a placebo or IV ibuprofen (100, 200, or 400 mg), and patients were given four hours for six doses. Subjects were excluded for platelet count <30 k and/or creatinine >3.0 mg/dL. Results At entry, there were no significant baseline differences between the IV ibuprofen group and placebo, n = 120. At four hours, the number (percentage) with T<101.0°F was: Placebo n = 9/28 (32%); 100 mg IV ibuprofen n = 19/31 (61%), P = 0.0264; 200 mg IV ibuprofen n = 21/30 (70%) P = 0.0043; 400 mg IV ibuprofen n = 24/31 (77%) P = 0.0005. A total of 53/120 patients (44%) were prospectively defined as critically ill at baseline and similar temperature reductions were observed in this subgroup. There were no statistically significant differences between treatment groups or when compared to placebo in transfusion, bleeding, renal failure or mortality. Conclusions All doses of IV ibuprofen tested reduced fever at four hours and throughout the first 24 hours of dosing. The 400 mg dose was effective in lowering temperature to normal and maintaining this over the first 24 hours of dosing. IV ibuprofen was effective in reducing fevers in critically ill and non-critically ill groups. Following 24 hours of administration of IV ibuprofen, no clinically significant differences in any safety parameter including renal function or bleeding occurred through the 28-day follow-up period. Trial registrations Clinicaltrials.gov registration number: NCT01131000.
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Cantu JA, Akkanti B, Mammen MJ, Raizen Y, Guntupalli KK. ADULT PULMONARY BLASTOMA: A TALE OF TWO HISTOLOGIES. Chest 2009. [DOI: 10.1378/chest.136.4_meetingabstracts.32s-e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Guntupalli KK, Reddy RM, Loutfi RH, Alapat PM, Bandi VD, Hanania NA. Evaluation of obstructive lung disease with vibration response imaging. J Asthma 2009; 45:923-30. [PMID: 19085584 DOI: 10.1080/02770900802395496] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
As optimal treatment and prognosis differ between asthma and COPD, a new diagnostic approach to differentiating between the two disorders would be clinically desirable. We evaluated the utility of vibration response imaging in differentiating between asthma and COPD. Sixty-six subjects with asthma or COPD were recorded, before and after the administration of a short-acting bronchodilator, using a computerized lung sound analysis device. Gray-scale images of breath sound distribution in the lungs, quantitative data in breath sound graphs (timing, amplitude) and automatic crackle and wheeze detection programs were used to differentiate between asthma and COPD subjects. Imaging data were compared with the clinical diagnosis, made by the standard methods (medical history, physical examination, and spirometric indices). Blinded evaluation of images demonstrated a significantly higher rate of improvement in image dynamics, shape and overall improvement following bronchodilator in subjects with asthma compared with those with COPD. Quantitative data showed distinct patterns in timing and amplitude for these two pathologies. Combined analyses based on qualitative image evaluation and quantitative data demonstrated an overall 85% accuracy (84% for asthma, 86% for COPD) in differentiating between asthma and COPD. Combined qualitative and quantitative evaluations of lung sounds are quite sensitive in distinguishing between lung sound recordings of COPD and asthma individuals. Lung sound features of synchronization in timing and intensity provide objective data that may further differentiate these two airway disorders.
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Guntupalli KK, Alapat PM, Bandi VD, Kushnir I. Validation of automatic wheeze detection in patients with obstructed airways and in healthy subjects. J Asthma 2009; 45:903-7. [PMID: 19085580 DOI: 10.1080/02770900802386008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Computerized lung-sound analysis is a sensitive and quantitative method to identify wheezing by its typical pattern on spectral analysis. We evaluated the accuracy of the VRI, a multi-sensor, computer-based device with an automated technique of wheeze detection. The method was validated in 100 sound files from seven subjects with asthma or chronic obstructive pulmonary disease and seven healthy subjects by comparison of auscultation findings, examination of audio files, and computer detection of wheezes. Three blinded physicians identified 40 sound files with wheezes and 60 sound files without wheezes. Sensitivity and specificity were 83% and 85%, respectively. Negative predictive value and positive predictive value were 89% and 79%, respectively. Overall inter-rater agreement was 84%. False positive cases were found to contain sounds that simulate wheezes, such as background noises with high frequencies or strong noises from the throat that could be heard and identified without a stethoscope. The present findings demonstrate that the wheeze detection algorithm has good accuracy, sensitivity, specificity, negative predictive value and positive predictive value for wheeze detection in regional analyses with a single sensor and multiple sensors. Results are similar to those reported in the literature. The device is user-friendly, requires minimal patient effort, and, distinct from other devices, it provides a dynamic image of breath sound distribution with wheeze detection output in less than 1 minute.
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Karnad DR, Guntupalli KK. Tuberculosis and Acute Lung Injury. Tuberculosis (Edinb) 2009. [DOI: 10.5005/jp/books/10992_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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