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Black LP, Hopson C, Barker G, Munson T, Henson M, Bertrand A, Daly-Crews K, Reddy ST, Guirgis FW. TRENDS IN CHOLESTEROL AND LIPOPROTEINS ARE ASSOCIATED WITH ACUTE RESPIRATORY DISTRESS SYNDROME INCIDENCE AND DEATH AMONG SEPSIS PATIENTS. Shock 2024; 61:260-265. [PMID: 38407817 PMCID: PMC10957110 DOI: 10.1097/shk.0000000000002295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
ABSTRACT Objective: Compare changes in cholesterol and lipoprotein levels occurring in septic patients with and without acute respiratory distress syndrome (ARDS) and by survivorship. Methods: We reanalyzed data from prospective sepsis studies. Cholesterol and lipoprotein levels were analyzed using univariate testing to detect changes between septic patients with or without ARDS, and among ARDS survivors compared with nonsurvivors at enrollment (first 24 h of sepsis) and 48 to 72 h later. Results: 214 patients with sepsis were included of whom 48 had ARDS and 166 did not have ARDS. Cholesterol and lipoproteins among septic ARDS versus non-ARDS showed similar enrollment levels. However, 48 to 72 h after enrollment, change in median total cholesterol (48/72 h - enrollment) was significantly different between septic ARDS (-4, interquartile range [IQR] -23.5, 6.5, n = 35) and non-ARDS (0, -10.0, 17.5, P = 0.04; n = 106). When compared by ARDS survivorship, ARDS nonsurvivors (n = 14) had lower median total cholesterol levels (75.5, IQR 68.4, 93.5) compared with ARDS survivors (113.0, IQR 84.0, 126.8, P = 0.022), and lower median enrollment low-density lipoprotein cholesterol (LDL-C) levels (27, IQR 19.5-34.5) compared with ARDS survivors (43, IQR 27-67, P = 0.013; n = 33). Apolipoprotein A-I levels were also significantly lower in ARDS nonsurvivors (n = 14) (87.6, IQR 76.45-103.64) compared with ARDS survivors (130.0, IQR 73.25-165.47, P = 0.047; n = 33). At 48 to 72 h, for ARDS nonsurvivors, median levels of low-density lipoprotein cholesterol (9.0, IQR 4.3, 18.0; n = 10), LDL-C (17.0, IQR 5.0, 29.0; n = 9), and total cholesterol (59.0, 45.3, 81.5; n = 10) were significantly lower compared with ARDS survivors' (n = 25) levels of low-density lipoprotein cholesterol (20.0, IQR 12.0-39.0, P = 0.014), LDL-C (42.0, IQR 27.0-58.0, P = 0.019), and total cholesterol (105.0, IQR 91.0, 115.0, P = 0.003). Conclusions: Change in total cholesterol was different in septic ARDS versus non-ARDS. Total cholesterol, LDL-C, and apolipoprotein A-I levels were lower in ARDS nonsurvivors compared with survivors. Future studies of dysregulated cholesterol metabolism in septic ARDS patients are needed to understand biology and links to potential therapies.
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Affiliation(s)
- Lauren Page Black
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Charlotte Hopson
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Grant Barker
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Taylor Munson
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Andrew Bertrand
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Kimberly Daly-Crews
- Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Srinivasa T Reddy
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Faheem W Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, Florida
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Strategies to DAMPen COVID-19-mediated lung and systemic inflammation and vascular injury. Transl Res 2021; 232:37-48. [PMID: 33358868 PMCID: PMC7749994 DOI: 10.1016/j.trsl.2020.12.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 02/07/2023]
Abstract
Approximately 15%-20% of patients infected with SARS-CoV-2 coronavirus (COVID-19) progress beyond mild and self-limited disease to require supplemental oxygen for severe pneumonia; 5% of COVID-19-infected patients further develop acute respiratory distress syndrome (ARDS) and multiorgan failure. Despite mortality rates surpassing 40%, key insights into COVID-19-induced ARDS pathology have not been fully elucidated and multiple unmet needs remain. This review focuses on the unmet need for effective therapies that target unchecked innate immunity-driven inflammation which drives unchecked vascular permeability, multiorgan dysfunction and ARDS mortality. Additional unmet needs including the lack of insights into factors predicting pathogenic hyperinflammatory viral host responses, limited approaches to address the vast disease heterogeneity in ARDS, and the absence of clinically-useful ARDS biomarkers. We review unmet needs persisting in COVID-19-induced ARDS in the context of the potential role for damage-associated molecular pattern proteins in lung and systemic hyperinflammatory host responses to SARS-CoV-2 infection that ultimately drive multiorgan dysfunction and ARDS mortality. Insights into promising stratification-enhancing, biomarker-based strategies in COVID-19 and non-COVID ARDS may enable the design of successful clinical trials of promising therapies.
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Key Words
- ace2, angiotensin converting enzyme 2
- ang-2, angiopoietin-2
- ards, acute respiratory distress syndrome
- covid-19, coronavirus disease 19 infection
- crp, c-reactive protein
- damps, damage-associated molecular pattern proteins
- enampt, extracellular nicotinamide phosphoribosyl-transferase
- ifnγ, interferon gamma
- il-1ra, interleukin 1 receptor antagonist
- il-6, interleukin 6
- ip-10, interferon gamma-induced protein 10
- irf7, interferon regulatory factor 7
- mcp1, monocyte chemoattractant protein 1
- mif, macrophage migration inhibition factor
- hmgb1, the high mobility group box 1 protein
- no, nitric oxide
- pamps, pathogen-associated molecular pattern proteins
- ripk1, receptor-interacting serine/threonine-protein kinase
- ros, reactive oxygen species
- sars-cov-2, severe acute respiratory syndrome-related coronavirus 2
- smi, small molecule inhibitor
- tlrs, toll-like family of receptors
- tnfα, tumor necrosis factor alpha
- vili, ventilator-induced lung injury
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Quijada H, Bermudez T, Kempf CL, Valera DG, Garcia AN, Camp SM, Song JH, Franco E, Burt JK, Sun B, Mascarenhas JB, Burns K, Gaber A, Oita RC, Reyes Hernon V, Barber C, Moreno-Vinasco L, Sun X, Cress AE, Martin D, Liu Z, Desai AA, Natarajan V, Jacobson JR, Dudek SM, Bime C, Sammani S, Garcia JG. Endothelial eNAMPT amplifies pre-clinical acute lung injury: efficacy of an eNAMPT-neutralising monoclonal antibody. Eur Respir J 2021; 57:2002536. [PMID: 33243842 PMCID: PMC8100338 DOI: 10.1183/13993003.02536-2020] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/05/2020] [Indexed: 12/11/2022]
Abstract
RATIONALE The severe acute respiratory syndrome coronavirus 2/coronavirus disease 2019 pandemic has highlighted the serious unmet need for effective therapies that reduce acute respiratory distress syndrome (ARDS) mortality. We explored whether extracellular nicotinamide phosphoribosyltransferase (eNAMPT), a ligand for Toll-like receptor (TLR)4 and a master regulator of innate immunity and inflammation, is a potential ARDS therapeutic target. METHODS Wild-type C57BL/6J or endothelial cell (EC)-cNAMPT -/- knockout mice (targeted EC NAMPT deletion) were exposed to either a lipopolysaccharide (LPS)-induced ("one-hit") or a combined LPS/ventilator ("two-hit")-induced acute inflammatory lung injury model. A NAMPT-specific monoclonal antibody (mAb) imaging probe (99mTc-ProNamptor) was used to detect NAMPT expression in lung tissues. Either an eNAMPT-neutralising goat polyclonal antibody (pAb) or a humanised monoclonal antibody (ALT-100 mAb) were used in vitro and in vivo. RESULTS Immunohistochemical, biochemical and imaging studies validated time-dependent increases in NAMPT lung tissue expression in both pre-clinical ARDS models. Intravenous delivery of either eNAMPT-neutralising pAb or mAb significantly attenuated inflammatory lung injury (haematoxylin and eosin staining, bronchoalveolar lavage (BAL) protein, BAL polymorphonuclear cells, plasma interleukin-6) in both pre-clinical models. In vitro human lung EC studies demonstrated eNAMPT-neutralising antibodies (pAb, mAb) to strongly abrogate eNAMPT-induced TLR4 pathway activation and EC barrier disruption. In vivo studies in wild-type and EC-cNAMPT -/- mice confirmed a highly significant contribution of EC-derived NAMPT to the severity of inflammatory lung injury in both pre-clinical ARDS models. CONCLUSIONS These findings highlight both the role of EC-derived eNAMPT and the potential for biologic targeting of the eNAMPT/TLR4 inflammatory pathway. In combination with predictive eNAMPT biomarker and NAMPT genotyping assays, this offers the opportunity to identify high-risk ARDS subjects for delivery of personalised medicine.
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Affiliation(s)
- Hector Quijada
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
- Co-first authors
| | - Tadeo Bermudez
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
- Co-first authors
| | - Carrie L. Kempf
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Daniel G. Valera
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Alexander N. Garcia
- Dept of Radiation Oncology, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Sara M. Camp
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Jin H. Song
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Evelyn Franco
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Jessica K. Burt
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Belinda Sun
- Dept of Pathology, University of Arizona Health Sciences, Tucson, AZ, USA
| | | | - Kimberlie Burns
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Amir Gaber
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Radu C. Oita
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | | | - Christy Barber
- Dept of Medical Imaging, University of Arizona Health Sciences, Tucson, AZ, USA
| | | | - Xiaoguang Sun
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Anne E. Cress
- Dept of Cellular and Molecular Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Diego Martin
- Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Zhonglin Liu
- Dept of Medical Imaging, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Ankit A. Desai
- Dept of Medicine, Indiana University, Indianapolis IN, USA
| | | | | | - Steven M. Dudek
- Dept of Medicine, University of Illinois Chicago, Chicago, IL, USA
| | - Christian Bime
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
| | - Saad Sammani
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
- Co-senior authors
| | - Joe G.N. Garcia
- Dept of Medicine, University of Arizona Health Sciences, Tucson, AZ, USA
- Co-senior authors
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Galassi MS, Arduini RG, Araújo ORD, Sousa RMK, Petrilli AS, Silva DCBD. ALVEOLAR RECRUITMENT MANEUVERS FOR CHILDREN WITH CANCER AND ACUTE RESPIRATORY DISTRESS SYNDROME: A FEASIBILITY STUDY. REVISTA PAULISTA DE PEDIATRIA 2021; 39:e2019275. [PMID: 33440404 PMCID: PMC7803003 DOI: 10.1590/1984-0462/2021/39/2019275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 01/19/2020] [Indexed: 12/16/2022]
Abstract
Objective: Acute respiratory distress syndrome (ARDS) can be a devastating condition in children with cancer and alveolar recruitment maneuvers (ARMs) can theoretically improve oxygenation and survival. The study aimed to assess the feasibility of ARMs in critically ill children with cancer and ARDS. Methods: We retrospectively analyzed 31 maneuvers in a series of 12 patients (median age of 8.9 years) with solid tumors (n=4), lymphomas (n=2), acute lymphoblastic leukemia (n=2), and acute myeloid leukemia (n=4). Patients received positive end-expiratory pressure from 25 up to 40 cmH20, with a delta pressure of 15 cmH2O for 60 seconds. We assessed blood gases pre- and post-maneuvers, as well as ventilation parameters, vital signs, hemoglobin, clinical signs of pulmonary bleeding, and radiological signs of barotrauma. Pre- and post-values were compared by the Wilcoxon test. Results: Median platelet count was 53,200/mm3. Post-maneuvers, mean arterial pressure decreased more than 20% in two patients, and four needed an increase in vasoactive drugs. Hemoglobin levels remained stable 24 hours after ARMs, and signs of pneumothorax, pneumomediastinum, or subcutaneous emphysema were absent. Fraction of inspired oxygen decreased significantly after ARMs (FiO2; p=0.003). Oxygen partial pressure (PaO2)/FiO2 ratio increased significantly (p=0.0002), and the oxygenation index was reduced (p=0.01), but all these improvements were transient. Recruited patients’ 28-day mortality was 58%. Conclusions: ARMs, although feasible in the context of thrombocytopenia, lead only to transient improvements, and can cause significant hemodynamic instability.
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Hiller HM, Taha S, Donham BP, Hackett AJ. Community hospital experience in the emergency management of COVID-19: Preventing morbidity and preserving resources. J Am Coll Emerg Physicians Open 2020; 1:1386-1391. [PMID: 33392544 PMCID: PMC7771776 DOI: 10.1002/emp2.12251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 01/08/2023] Open
Abstract
An incredible amount of information has been published regarding inpatient management of patients with COVID-19. Although this is vitally important, critical interventions that occur in the emergency department (ED) can have a profound impact on the individual patient and the healthcare system as a whole. Much has been written regarding care in large centers, but there has been little discussion regarding similar patients in community settings. Prior to the pandemic, large centers were able to accept patients that outstripped the resources in community hospital settings, but currently we foresee that many community centers will begin to manage more complex cases without referral. As physicians in a medium-sized community academic center, we aim to enumerate community-hospital-relevant guidance for ED care that focuses on adherence to available evidence-based medicine, including early aggressive supplemental oxygenation, awake proning, and methods to improve oxygenation and ultimately delay intubation as long as safely possible. Equally importantly, it was recognized early that adjustments to medication regimens (eg, sedation) and personal protective equipment (PPE) use must be made in the ED to conserve those same resources for long-term use in inpatient units and improve the functionality of the hospital system as a whole. It is our hope that this article may serve as a framework for similar community-based hospitals to create their own protocols to optimize resource utilization, staff safety, and patient care.
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Affiliation(s)
- Hugh M. Hiller
- Emergency Department, Carl R. DarnallArmy Medical CenterFort HoodTexasUSA
| | - Sammy Taha
- Emergency Department, Carl R. DarnallArmy Medical CenterFort HoodTexasUSA
| | - Benjamin P. Donham
- Emergency Department, Carl R. DarnallArmy Medical CenterFort HoodTexasUSA
| | - Anthony J. Hackett
- Emergency Department, Carl R. DarnallArmy Medical CenterFort HoodTexasUSA
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Prekker ME, Donelan C, Ambur S, Driver BE, O'Brien-Lambert A, Hottinger DG, Adams AB. Adoption of low tidal volume ventilation in the emergency department: A quality improvement intervention. Am J Emerg Med 2019; 38:763-767. [PMID: 31235218 DOI: 10.1016/j.ajem.2019.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/07/2019] [Accepted: 06/14/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Ventilator tidal volumes of >8 mL/kg of predicted body weight (PBW) may increase the risk of lung injury. We sought to evaluate the impact of a quality improvement intervention among intubated Emergency Department (ED) patients to protocolize the prescription of low tidal volume ventilation. METHODS In this before-and-after study, the average tidal volume delivered to ED patients receiving volume assist-control ventilation was compared before (2007-2014) and after (2015-2016) implementation of a ventilator initiation protocol (the quality improvement intervention). The intervention emphasized 1) measurement of the patient's height to calculate PBW and therefore tailor the tidal volume to estimated lung size (<8 mL/kg PBW), and 2) focused education and reference materials for ED physicians and respiratory therapists. RESULTS Among ventilated ED patients meeting inclusion criteria in the before (N = 2185) and after (N = 774) cohorts, the mean (±SD) tidal volume decreased from 9.0 ± 1.4 mL/kg to 7.2 ± 0.9 mL/kg PBW following the intervention (absolute difference 1.8 mL/kg, 95% confidence interval 1.7 to 1.9 mL/kg, p < 0.001). The proportion of patients receiving low tidal volume ventilation increased after the intervention (72%), as compared to before (23%). Low tidal volume ventilation continued to be utilized at 24 h after ICU admission in patients who remained intubated in the cohort following the intervention (mean tidal volume 7.3 mL/kg PBW). CONCLUSIONS Pairing a ventilator initiation protocol with focused education and resources for emergency physicians and respiratory therapists was associated with a significant reduction in tidal volume delivered to ED patients.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Crystal Donelan
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Sum Ambur
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Alex O'Brien-Lambert
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Daniel G Hottinger
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States of America.
| | - Alexander B Adams
- Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, MN, United States of America; Respiratory Therapy Department, Hennepin County Medical Center, Minneapolis, MN, United States of America
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The effect of emergency department crowding on lung-protective ventilation utilization for critically ill patients. J Crit Care 2019; 52:40-47. [PMID: 30954692 DOI: 10.1016/j.jcrc.2019.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/16/2019] [Accepted: 03/21/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To measure effects of ED crowding on lung-protective ventilation (LPV) utilization in critically ill ED patients. METHODS This is a retrospective cohort study of adult mechanically ventilated ED patients admitted to the medical intensive care unit (MICU), over a 3.5-year period at a single academic tertiary care hospital. Clinical data, including reason for intubation, severity of illness (MPM0-III), acute respiratory distress syndrome (ARDS) risk score (EDLIPS), and ventilator settings were extracted via electronic query of electronic health record and standardized chart abstraction. Crowding metrics were obtained at 5-min intervals and averaged over the ED stay, stratified by acuity and disposition. Multivariate logistic regression was used to predict likelihood of LPV prior to ED departure. RESULTS Mechanical ventilation was used in 446 patients for a median ED duration of 3.7 h (interquartile ratio, IQR, 2.3, 5.6). Mean MPM0-III score was 32.5 ± 22.7, with high risk for ARDS (EDLIPS ≥5) seen in 373 (82%) patients. Initial and final ED ventilator settings differed in 134 (30.0%) patients, of which only 47 (35.1%) involved tidal volume changes. Higher percentages of active ED patients (workup in-progress) and those requiring eventual admission were associated with lower odds of LPV utilization by ED departure (OR 0.97, 95%CI 0.94-1.00; OR 0.97, 95%CI 0.94-1.00, respectively). In periods of high volume, ventilator adjustments to settings other than the tidal volume were associated with higher odds of LPV utilization. Reason for intubation, MPM0-III, and EDLIPS were not associated with LPV utilization, with no interactions detected in times of crowding. CONCLUSIONS ED patients remain on suboptimal tidal volume settings with infrequent ventilator adjustments during the ED stay. Hospitals should focus on both systemic factors and bedside physician and/or respiratory therapist interventions to increase LPV utilization in times of ED boarding and crowding for all patients.
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Kroll M, Das J, Siegler J. Can Altering Grip Technique and Bag Size Optimize Volume Delivered with Bag-Valve-Mask by Emergency Medical Service Providers? PREHOSP EMERG CARE 2018; 23:210-214. [PMID: 30130437 DOI: 10.1080/10903127.2018.1489020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Emergency Medical Services (EMS) professionals rely on the bag-valve-mask (BVM) to provide life-saving positive-pressure ventilation in the prehospital setting. Multiple emergency medicine and critical care studies have shown that lung-protective ventilation protocols reduce morbidity and mortality. A recent study has shown that the volumes typically delivered by EMS professionals with the adult BVM are often higher than recommended by lung-protective ventilation protocols. Our primary objective was to determine if a group of EMS professionals could reduce the volume delivered by adjusting the way the BVM was held. Secondary objectives included 1) if the adjusted grip allowed for volumes more consistent with lung-protection ventilation strategies and 2) comparing volumes to similar grip strategies used with a smaller BVM. METHODS A patient simulator of a head and thorax was used to record respiratory rate, tidal volume, peak pressure, and minute volume delivered by participants for 1 minute each across 6 different scenarios: 3 different grips (using the thumb and either 3 fingers, 2 fingers, or one finger) with 2 different sized BVMs (adult and pediatric). Trials were randomized by blindly selecting a paper with the scenario listed. A convenience sample of EMS providers was used based on EMS provider and research staff availability. RESULTS We enrolled 50 providers from a large, busy, urban hospital-based EMS agency a mean 8.60 (SD = 9.76) years of experience. Median volumes for each scenario were 836.0 mL, 834.5 mL, and 794 mL for the adult BMV (p = 0.003); and 576.0 mL, 571.5 mL, and 547.0 mL for the pediatric BVM (p < 0.001). Across all 3 grips, the pediatric BVM provided more breaths within the recommended volume range for a 70 kg patient (46.4% vs. 0.4%; p < 0.001) with only a 1.1% of breaths below the recommended tidal volume. CONCLUSION The study suggests that it is possible to alter the volume provided by the BVM by altering the grip on the BVM. The tidal volumes recorded with the pediatric BVM were above recommended range in 2 of the 3 grips. The volumes of the pediatric BVM were overall more consistent with lung-protective ventilation volumes when compared to all 3 finger-grips of the adult BVM.
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Chalkias A, Xanthos T, Papageorgiou E, Anania A, Beloukas A, Pavlopoulos F. Intraoperative initiation of a modified ARDSNet protocol increases survival of septic patients with severe acute respiratory distress syndrome. Heart Lung 2018; 47:616-621. [PMID: 30097303 DOI: 10.1016/j.hrtlng.2018.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the intraoperative initiation and feasibility of a modified NIH-NHLBI ARDS Network Mechanical Ventilation Protocol (mARDSNet protocol) in septic patients with severe ARDS. MATERIALS AND METHODS This prospective observational study included consecutive adult septic patients with severe ARDS who underwent emergency abdominal surgery prior to intensive care unit (ICU) admission. The primary outcome was survival to hospital discharge and at 90 days. Secondary outcomes were intraoperative adverse events and ICU length of stay. RESULTS Seven patients were included. A statistically significant difference in lung compliance [ε=0.150, F(1.053, 3.158)=31.098, p=0.010] and driving pressure [ε=0.263, F(1.844, 5.532)=7.042, p=0.031] was observed with time, while plateau pressure did not changed significantly during surgery [ε=0.322, F(2.256, 6.769)=1.920, p=0.219]. Also, PEEP values were constantly increased during surgery [ε=0.252, F(1.766, 5.297)=9.994, p=0.017], with the highest values being observed towards to the end of the procedure. No intraoperative adverse events were observed. Mean (±SD) ICU length of stay was 10.43 (±2.64) days, while all patients survived to hospital discharge and at 90 days. CONCLUSIONS The intraoperative implementation of our mARDSNet protocol is feasible and may increase the survival of septic patients with severe ARDS if initiated prior to ICU admission.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology and Perioperative Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larisa, Greece; Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece.
| | | | - Effie Papageorgiou
- Department of BioMedical Sciences, University of West Attica, Athens, Greece
| | - Artemis Anania
- Department of Anesthesiology, Tzaneio General Hospital, Piraeus, Greece
| | - Apostolos Beloukas
- Department of BioMedical Sciences, University of West Attica, Athens, Greece; Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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Amezcua-Gutiérrez M, Montoya-Rojo J, Castañón-González J, Zamora-Gómez S, Gorordo-Delsol L, Hernández-López G, Pérez-Nieto O, Cabanillas-Cervantes A, Garduño-López J, Lima-Lucero I, Cruz-Montesinos S. The maximum expression of hypoxia and hypoventilation: Acute respiratory distress syndrome. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2018. [DOI: 10.1016/j.hgmx.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Hemmes SNT, Ball L, Serpa Neto A, de Abreu MG, Pelosi P, Schultz MJ. Are height and weight estimates in ED patients reliable for setting the ventilator? Am J Emerg Med 2017; 35:1963-1964. [PMID: 28610772 PMCID: PMC8543644 DOI: 10.1016/j.ajem.2017.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/04/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sabrine N T Hemmes
- Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands; Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Ary Serpa Neto
- Dept. of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany; Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands; Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Protective lung strategies: A cross sectional survey of nurses knowledge and use in the emergency department. ACTA ACUST UNITED AC 2017; 20:87-91. [PMID: 28268159 DOI: 10.1016/j.aenj.2017.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Mechanical ventilation (MV) is commonly used in emergency departments (EDs). Protective lung strategies (PLS), comprising of low tidal volume (6mL/kg), control of oxygen and plateau pressures, and administration of positive end expiratory pressure (PEEP) has been shown to reduces the risks associated with MV but there is little evidence exists about nurses' knowledge or application of PLS. Our aim was to explore nurses knowledge and application of PLS in Australian EDs. METHODS Descriptive, exploratory design utilising an online questionnaire. A convenience sample was recruited via the College of Emergency Nursing Australasia mailing list and secondary snowball sampling was used to optimise response rate. RESULTS There were 157 participants. PLS are being used in most EDs (n=104, 75%) and clinical practice guidelines (CPG) are often available (n=86, 62%). Most ED ventilators are capable of implementing PLS, but measurement of plateau pressures was infrequent (n=46%). Participants demonstrate appropriate knowledge, but reported varying levels of confidence and perceived autonomy when implementing PLS in the ED. CONCLUSION PLS are being used in Australian EDs, aligning with best available evidence. Nursing staff have good levels of PLS knowledge. Development of an evidence-based CPG may improve confidence when implementing PLS and may pave the way for ED nurses to expand their scope of practice.
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Maltesen RG, Rasmussen BS, Pedersen S, Hanifa MA, Kucheryavskiy S, Kristensen SR, Wimmer R. Metabotyping Patients' Journeys Reveals Early Predisposition to Lung Injury after Cardiac Surgery. Sci Rep 2017; 7:40275. [PMID: 28074924 PMCID: PMC5225494 DOI: 10.1038/srep40275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/05/2016] [Indexed: 12/30/2022] Open
Abstract
Cardiovascular disease is the leading cause of death worldwide and patients with severe symptoms undergo cardiac surgery. Even after uncomplicated surgeries, some patients experience postoperative complications such as lung injury. We hypothesized that the procedure elicits metabolic activity that can be related to the disease progression, which is commonly observed two-three days postoperatively. More than 700 blood samples were collected from 50 patients at nine time points pre-, intra-, and postoperatively. Dramatic metabolite shifts were observed during and immediately after the intervention. Prolonged surgical stress was linked to an augmented anaerobic environment. Time series analysis showed shifts in purine-, nicotinic acid-, tyrosine-, hyaluronic acid-, ketone-, fatty acid, and lipid metabolism. A characteristic 'metabolic biosignature' was identified correlating with the risk of developing postoperative complications two days before the first clinical signs of lung injury. Hence, this study demonstrates the link between intra- and postoperative time-dependent metabolite changes and later postoperative outcome. In addition, the results indicate that metabotyping patients' journeys early, during or just after the end of surgery, may have potential impact in hospitals for the early diagnosis of postoperative lung injury, and for the monitoring of therapeutics targeting disease progression.
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Affiliation(s)
- Raluca Georgiana Maltesen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Denmark
- Department of Chemistry and Bioscience, Aalborg University, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Denmark
| | - Shona Pedersen
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Denmark
- Department of Clinical Biochemistry, Aalborg University Hospital, Denmark
| | - Munsoor Ali Hanifa
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Denmark
| | | | - Søren Risom Kristensen
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Denmark
- Department of Clinical Biochemistry, Aalborg University Hospital, Denmark
| | - Reinhard Wimmer
- Department of Chemistry and Bioscience, Aalborg University, Denmark
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Siegler J, Kroll M, Wojcik S, Moy HP. Can EMS Providers Provide Appropriate Tidal Volumes in a Simulated Adult-sized Patient with a Pediatric-sized Bag-Valve-Mask? PREHOSP EMERG CARE 2016; 21:74-78. [PMID: 27690714 DOI: 10.1080/10903127.2016.1227003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In the prehospital setting, Emergency Medical Services (EMS) professionals rely on providing positive pressure ventilation with a bag-valve-mask (BVM). Multiple emergency medicine and critical care studies have shown that lung-protective ventilation protocols reduce morbidity and mortality. Our primary objective was to determine if a group of EMS professionals could provide ventilations with a smaller BVM that would be sufficient to ventilate patients. Secondary objectives included 1) if the pediatric bag provided volumes similar to lung-protective ventilation in the hospital setting and 2) compare volumes provided to the patient depending on the type of airway (mask, King tube, and intubation). METHODS Using a patient simulator of a head and thorax that was able to record respiratory rate, tidal volume, peak pressure, and minute volume via a laptop computer, participants were asked to ventilate the simulator during six 1-minute ventilation tests. The first scenario was BVM ventilation with an oropharyngeal airway in place ventilating with both an adult- and pediatric-sized BVM, the second scenario had a supraglottic airway and both bags, and the third scenario had an endotracheal tube and both bags. Participants were enrolled in convenience manner while they were on-duty and the research staff was able to travel to their stations. Prior to enrolling, participants were not given any additional training on ventilation skills. RESULTS We enrolled 50 providers from a large, busy, urban fire-based EMS agency with 14.96 (SD = 9.92) mean years of experience. Only 1.5% of all breaths delivered with the pediatric BVM during the ventilation scenarios were below the recommended tidal volume. A greater percentage of breaths delivered in the recommended range occurred when the pediatric BVM was used (17.5% vs 5.1%, p < 0.001). Median volumes for each scenario were 570.5mL, 664.0mL, 663.0mL for the pediatric BMV and 796.0mL, 994.5mL, 981.5mL for the adult BVM. In all three categories of airway devices, the pediatric BVM provided lower median tidal volumes (p < 0.001). CONCLUSION The study suggests that ventilating an adult patient is possible with a smaller, pediatric-sized BVM. The tidal volumes recorded with the pediatric BVM were more consistent with lung-protective ventilation volumes.
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Sadowitz B, Jain S, Kollisch-Singule M, Satalin J, Andrews P, Habashi N, Gatto LA, Nieman G. Preemptive mechanical ventilation can block progressive acute lung injury. World J Crit Care Med 2016; 5:74-82. [PMID: 26855896 PMCID: PMC4733459 DOI: 10.5492/wjccm.v5.i1.74] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/15/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Mortality from acute respiratory distress syndrome (ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation (APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury (ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.
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Nieman GF, Gatto LA, Habashi NM. Reducing acute respiratory distress syndrome occurrence using mechanical ventilation. World J Respirol 2015; 5:188-198. [DOI: 10.5320/wjr.v5.i3.188] [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: 03/14/2015] [Revised: 07/01/2015] [Accepted: 07/17/2015] [Indexed: 02/06/2023] Open
Abstract
The standard treatment for acute respiratory distress syndrome (ARDS) is supportive in the form of low tidal volume ventilation applied after significant lung injury has already developed. Nevertheless, ARDS mortality remains unacceptably high (> 40%). Indeed, once ARDS is established it becomes refractory to treatment, and therefore avoidance is key. However, preventive techniques and therapeutics to reduce the incidence of ARDS in patients at high-risk have not been validated clinically. This review discusses the current data suggesting that preemptive application of the properly adjusted mechanical breath can block progressive acute lung injury and significantly reduce the occurrence of ARDS.
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Fuller BM, Mohr NM, Miller CN, Deitchman AR, Levine BJ, Castagno N, Hassebroek EC, Dhedhi A, Scott-Wittenborn N, Grace E, Lehew C, Kollef MH. Mechanical Ventilation and ARDS in the ED: A Multicenter, Observational, Prospective, Cross-sectional Study. Chest 2015; 148:365-374. [PMID: 25742126 PMCID: PMC4524326 DOI: 10.1378/chest.14-2476] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 02/02/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment. METHODS This study was a multicenter, observational, prospective, cohort study aimed at analyzing ventilation practices in the ED. The primary outcome was the incidence of ARDS after admission. Multivariable logistic regression was used to determine the predictors of ARDS. RESULTS We analyzed 219 patients receiving mechanical ventilation to assess ED ventilation practices. Median tidal volume was 7.6 mL/kg predicted body weight (PBW) (interquartile range, 6.9-8.9), with a range of 4.3 to 12.2 mL/kg PBW. Lung-protective ventilation was used in 122 patients (55.7%). The incidence of ARDS after admission from the ED was 14.7%, with a mean onset of 2.3 days. Progression to ARDS was associated with higher illness severity and intubation in the prehospital environment or transferring facility. Of the 15 patients with ARDS in the ED (6.8%), lung-protective ventilation was used in seven (46.7%). Patients who progressed to ARDS experienced greater duration in organ failure and ICU length of stay and higher mortality. CONCLUSIONS Lung-protective ventilation is infrequent in patients receiving mechanical ventilation in the ED, regardless of ARDS status. Progression to ARDS is common after admission, occurs early, and worsens outcome. Patient- and treatment-related factors present in the ED are associated with ARDS. Given the limited treatment options for ARDS, and the early onset after admission from the ED, measures to prevent onset and to mitigate severity should be instituted in the ED. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Brian M Fuller
- Department of Emergency Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO; Department of Anesthesiology, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO.
| | - Nicholas M Mohr
- Department of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Christopher N Miller
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew R Deitchman
- Department of Emergency Medicine, Christiana Care Health System, Newark, DE
| | - Brian J Levine
- Department of Emergency Medicine, Christiana Care Health System, Newark, DE
| | | | | | - Adam Dhedhi
- Saint Louis University School of Medicine, St. Louis, MO
| | | | | | - Courtney Lehew
- Department of Emergency Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO
| | - Marin H Kollef
- Division of Critical Care, and the Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, MO
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Stoltze AJ, Wong TS, Harland KK, Ahmed A, Fuller BM, Mohr NM. Prehospital tidal volume influences hospital tidal volume: A cohort study. J Crit Care 2015; 30:495-501. [PMID: 25813548 DOI: 10.1016/j.jcrc.2015.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/05/2015] [Accepted: 02/12/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE The purposes of the study are to describe current practice of ventilation in a modern air medical system and to measure the association of ventilation strategy with subsequent ventilator care and acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS Retrospective observational cohort study of intubated adult patients (n = 235) transported by a university-affiliated air medical transport service to a 711-bed tertiary academic center between July 2011 and May 2013. Low tidal volume ventilation was defined as tidal volumes less than or equal to 8 mL/kg predicted body weight. Multivariable regression was used to measure the association between prehospital tidal volume, hospital ventilation strategy, and ARDS. RESULTS Most patients (57%) were ventilated solely with bag valve ventilation during transport. Mean tidal volume of mechanically ventilated patients was 8.6 mL/kg predicted body weight (SD, 0.2 mL/kg). Low tidal volume ventilation was used in 13% of patients. Patients receiving low tidal volume ventilation during air medical transport were more likely to receive low tidal volume ventilation in the emergency department (P < .001) and intensive care unit (P = .015). Acute respiratory distress syndrome was not associated with prehospital tidal volume (P = .840). CONCLUSIONS Low tidal volume ventilation was rare during air medical transport. Air transport ventilation strategy influenced subsequent ventilation but was not associated with ARDS.
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Affiliation(s)
- Andrew J Stoltze
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Terrence S Wong
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242
| | - Brian M Fuller
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO 63110; Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA 52242.
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Wright BJ. Lung-protective Ventilation Strategies and Adjunctive Treatments for the Emergency Medicine Patient with Acute Respiratory Failure. Emerg Med Clin North Am 2014; 32:871-87. [DOI: 10.1016/j.emc.2014.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fuller BM, Mohr NM, Graetz TJ, Lynch IP, Dettmer M, Cullison K, Coney T, Gogineni S, Gregory R. The impact of cardiac dysfunction on acute respiratory distress syndrome and mortality in mechanically ventilated patients with severe sepsis and septic shock: an observational study. J Crit Care 2014; 30:65-70. [PMID: 25179413 DOI: 10.1016/j.jcrc.2014.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/28/2014] [Accepted: 07/30/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is associated with significant mortality and morbidity in survivors. Treatment is only supportive, therefore elucidating modifiable factors that could prevent ARDS could have a profound impact on outcome. The impact that sepsis-associated cardiac dysfunction has on ARDS is not known. MATERIALS AND METHODS In this retrospective observational cohort study of mechanically ventilated patients with severe sepsis and septic shock, 122 patients were assessed for the impact of sepsis-associated cardiac dysfunction on incidence of ARDS (primary outcome) and mortality. RESULTS Sepsis-associated cardiac dysfunction occurred in 44 patients (36.1%). There was no association of sepsis-associated cardiac dysfunction with ARDS incidence (p= 0.59) or mortality, and no association with outcomes in patients that did progress to ARDS after admission. Multivariable logistic regression demonstrated that higher BMI was associated with progression to ARDS (adjusted OR 11.84, 95% CI 1.24 to 113.0, p= 0.02). CONCLUSIONS Cardiac dysfunction in mechanically ventilated patients with sepsis did not impact ARDS incidence, clinical outcome in ARDS patients, or mortality. This contrasts against previous investigations demonstrating an influence of nonpulmonary organ dysfunction on outcome in ARDS. Given the frequency of ARDS as a sequela of sepsis, the impact of cardiac dysfunction on outcome should be further studied.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO.
| | - Nicholas M Mohr
- Department of Emergency Medicine, Department of Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Thomas J Graetz
- Department of Anesthesiology, Division of Critical Care, Division of Cardiothoracic Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Isaac P Lynch
- Department of Anesthesiology, Division of Critical Care, Division of Cardiothoracic Anesthesiology, Washington University School of Medicine, St Louis, MO
| | - Matthew Dettmer
- Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO
| | - Kevin Cullison
- Division of Emergency Medicine, Washington University School of Medicine, St Louis, MO
| | - Talia Coney
- Saint Louis University School of Medicine, St Louis, MO
| | | | - Robert Gregory
- Southern Illinois University School of Medicine, Springfield, IL
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Tulman DB, Stawicki SPA, Whitson BA, Gupta SC, Tripathi RS, Firstenberg MS, Hayes D, Xu X, Papadimos TJ. Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies. BMC Anesthesiol 2014; 14:65. [PMID: 25110462 PMCID: PMC4126084 DOI: 10.1186/1471-2253-14-65] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
Background Following the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently “rescue” a significant proportion of those affected. Discussion Here we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices. Summary Since the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.
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Affiliation(s)
- David B Tulman
- Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA
| | - Stanislaw P A Stawicki
- Department of Surgery, Division of Critical Care, Trauma, and Burn, Wexner Medical Center at The Ohio State University, 410 W 10th Ave, Columbus 43210, OH, USA
| | - Bryan A Whitson
- Department of Surgery, Division of Cardiac Surgery, Wexner Medical Center at The Ohio State University, 410 W 10th Ave, Columbus 43210, OH, USA
| | - Saarik C Gupta
- Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA ; Northeast Ohio Medical University, 4209 SR 44, PO Box 95, Rootstown 44272, OH, USA
| | - Ravi S Tripathi
- Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA
| | | | - Don Hayes
- Pulmonary Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus 43205, OH, USA
| | - Xuzhong Xu
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical College, 2 Fuxue Road, 32500 Zhejiang, China
| | - Thomas J Papadimos
- Department of Anesthesiology, Wexner Medical Center at The Ohio State, University, 410 W 10th Ave, Columbus 43210, OH, USA
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What’s New in Shock? May 2014. Shock 2014; 41:369-72. [DOI: 10.1097/shk.0000000000000157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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