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Johnson SW, Wang RS, Winter MR, Gillmeyer KR, Zeder K, Klings ES, Goldstein RH, Wiener RS, Maron BA. Cluster analysis identifies novel real-world lung disease-pulmonary hypertension subphenotypes: implications for treatment response. ERJ Open Res 2024; 10:00959-2023. [PMID: 38770008 PMCID: PMC11103711 DOI: 10.1183/23120541.00959-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/15/2024] [Indexed: 05/22/2024] Open
Abstract
Background Clinical trials repurposing pulmonary arterial hypertension (PAH) therapies to patients with lung disease- or hypoxia-pulmonary hypertension (PH) (classified as World Health Organization Group 3 PH) have failed to show a consistent benefit. However, Group 3 PH clinical heterogeneity suggests robust phenotyping may inform detection of treatment-responsive subgroups. We hypothesised that cluster analysis would identify subphenotypes with differential responses to oral PAH therapy. Methods Two k-means analyses were performed on a national cohort of US veterans with Group 3 PH; an inclusive model (I) of all treated patients (n=196) and a haemodynamic model (H) limited to patients with right heart catheterisations (n=112). The primary outcome was organ failure or all-cause mortality by cluster. An exploratory analysis evaluated within-cluster treatment effects. Results Three distinct clusters of Group 3 PH patients were identified. In the inclusive model (C1I n=43, 21.9%; C2I n=102, 52.0%; C3I n=51, 26.0%), lung disease and spirometry drove cluster assignment. By contrast, in the haemodynamic model (C1H n=44, 39.3%; C2H n=43, 38.4%; C3H n=25, 22.3%), right heart catheterisation data surpassed the importance of lung disease and spirometry. In the haemodynamic model, compared to C3H, C1H experienced the greatest hazard for respiratory failure or death (HR 6.1, 95% CI 3.2-11.8). In an exploratory analysis, cluster determined treatment response (p=0.006). Conclusions regarding within-cluster treatment responses were limited by significant differences between select variables in the treated and untreated groups. Conclusions Cluster analysis identifies novel real-world subphenotypes of Group 3 PH patients with distinct clinical trajectories. Future studies may consider this methodological approach to identify subgroups of heterogeneous patients that may be responsive to existing pulmonary vasodilatory therapies.
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Affiliation(s)
- Shelsey W. Johnson
- VA Boston Healthcare System, Boston, MA, USA
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, and Boston University School of Medicine, Boston, MA, USA
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rui-Sheng Wang
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael R. Winter
- Boston University School of Public Health, Biostatistics and Epidemiology Data Analytics Center, Boston, MA, USA
| | - Kari R. Gillmeyer
- VA Boston Healthcare System, Boston, MA, USA
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, and Boston University School of Medicine, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Katarina Zeder
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- The University of Maryland-Institute for Health Computing, Bethesda, MD, USA
| | - Elizabeth S. Klings
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, and Boston University School of Medicine, Boston, MA, USA
| | | | - Renda Soylemez Wiener
- VA Boston Healthcare System, Boston, MA, USA
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, and Boston University School of Medicine, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Bradley A. Maron
- VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- The University of Maryland-Institute for Health Computing, Bethesda, MD, USA
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Sathe NA, Zelnick LR, Morrell ED, Bhatraju PK, Kerchberger VE, Hough CL, Ware LB, Fohner AE, Wurfel MM. Development and External Validation of Models to Predict Persistent Hypoxemic Respiratory Failure for Clinical Trial Enrichment. Crit Care Med 2024; 52:764-774. [PMID: 38197736 PMCID: PMC11018468 DOI: 10.1097/ccm.0000000000006181] [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: 01/11/2024]
Abstract
OBJECTIVES Improving the efficiency of clinical trials in acute hypoxemic respiratory failure (HRF) depends on enrichment strategies that minimize enrollment of patients who quickly resolve with existing care and focus on patients at high risk for persistent HRF. We aimed to develop parsimonious models predicting risk of persistent HRF using routine data from ICU admission and select research immune biomarkers. DESIGN Prospective cohorts for derivation ( n = 630) and external validation ( n = 511). SETTING Medical and surgical ICUs at two U.S. medical centers. PATIENTS Adults with acute HRF defined as new invasive mechanical ventilation (IMV) and hypoxemia on the first calendar day after ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated discrimination, calibration, and practical utility of models predicting persistent HRF risk (defined as ongoing IMV and hypoxemia on the third calendar day after admission): 1) a clinical model with least absolute shrinkage and selection operator (LASSO) selecting Pa o2 /F io2 , vasopressors, mean arterial pressure, bicarbonate, and acute respiratory distress syndrome as predictors; 2) a model adding interleukin-6 (IL-6) to clinical predictors; and 3) a comparator model with Pa o2 /F io2 alone, representing an existing strategy for enrichment. Forty-nine percent and 69% of patients had persistent HRF in derivation and validation sets, respectively. In validation, both LASSO (area under the receiver operating characteristic curve, 0.68; 95% CI, 0.64-0.73) and LASSO + IL-6 (0.71; 95% CI, 0.66-0.76) models had better discrimination than Pa o2 /F io2 (0.64; 95% CI, 0.59-0.69). Both models underestimated risk in lower risk deciles, but exhibited better calibration at relevant risk thresholds. Evaluating practical utility, both LASSO and LASSO + IL-6 models exhibited greater net benefit in decision curve analysis, and greater sample size savings in enrichment analysis, compared with Pa o2 /F io2 . The added utility of LASSO + IL-6 model over LASSO was modest. CONCLUSIONS Parsimonious, interpretable models that predict persistent HRF may improve enrichment of trials testing HRF-targeted therapies and warrant future validation.
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Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Leila R. Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
| | - V. Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lorraine B, Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Alison E Fohner
- Department of Epidemiology, School of Public Health, University of Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
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3
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Grolleau F, Petit F, Gaudry S, Diard É, Quenot JP, Dreyfuss D, Tran VT, Porcher R. Personalizing renal replacement therapy initiation in the intensive care unit: a reinforcement learning-based strategy with external validation on the AKIKI randomized controlled trials. J Am Med Inform Assoc 2024; 31:1074-1083. [PMID: 38452293 PMCID: PMC11031229 DOI: 10.1093/jamia/ocae004] [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] [Received: 09/13/2023] [Revised: 12/13/2023] [Accepted: 01/16/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE The timely initiation of renal replacement therapy (RRT) for acute kidney injury (AKI) requires sequential decision-making tailored to individuals' evolving characteristics. To learn and validate optimal strategies for RRT initiation, we used reinforcement learning on clinical data from routine care and randomized controlled trials. MATERIALS AND METHODS We used the MIMIC-III database for development and AKIKI trials for validation. Participants were adult ICU patients with severe AKI receiving mechanical ventilation or catecholamine infusion. We used a doubly robust estimator to learn when to start RRT after the occurrence of severe AKI for three days in a row. We developed a "crude strategy" maximizing the population-level hospital-free days at day 60 (HFD60) and a "stringent strategy" recommending RRT when there is significant evidence of benefit for an individual. For validation, we evaluated the causal effects of implementing our learned strategies versus following current best practices on HFD60. RESULTS We included 3748 patients in the development set and 1068 in the validation set. Through external validation, the crude and stringent strategies yielded an average difference of 13.7 [95% CI -5.3 to 35.7] and 14.9 [95% CI -3.2 to 39.2] HFD60, respectively, compared to current best practices. The stringent strategy led to initiating RRT within 3 days in 14% of patients versus 38% under best practices. DISCUSSION Implementing our strategies could improve the average number of days that ICU patients spend alive and outside the hospital while sparing RRT for many. CONCLUSION We developed and validated a practical and interpretable dynamic decision support system for RRT initiation in the ICU.
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Affiliation(s)
- François Grolleau
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - François Petit
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
| | - Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Avicenne, Université Sorbonne Paris Nord, Bobigny, 93430, France
- Health Care Simulation Center, UFR SMBH, Sorbonne Paris Cité, Bobigny, 93017, France
- INSERM UMR S1155, Sorbonne Université, CORAKID, Hôpital Tenon, Paris, 75020, France
| | - Élise Diard
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, 21000, France
- Lipness Team, INSERM Research Center, LNC-UMR1231 and LabEx LipSTIC, Dijon, 21000, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, 21000, France
| | - Didier Dreyfuss
- INSERM UMR S1155, Sorbonne Université, CORAKID, Hôpital Tenon, Paris, 75020, France
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Hôpital Louis Mourier, AP-HP, Université Paris-Cité, Paris, F-75018, France
| | - Viet-Thi Tran
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
| | - Raphaël Porcher
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), Paris, F-75004, France
- Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, F-75004, France
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Greenstein YY, Hubel K, Froess J, Wisniewski SR, Venugopal V, Lai YH, Berger JS, Chang SY, Colovos C, Shah F, Kornblith LZ, Lawler PR, Gaddh M, Guerrero RM, Nkemdirim W, Lopes RD, Reynolds HR, Amigo JS, Wahid L, Zahra A, Goligher EC, Zarychanski R, Leifer E, Huang DT, Neal MD, Hochman JS, Cushman M, Gong MN. Symptoms and Impaired Quality of Life After COVID-19 Hospitalization: Effect of Therapeutic Heparin in Non-ICU Patients in the Accelerating COVID-19 Therapeutic Interventions and Vaccines 4 Acute Trial: Effect on 3-Month Symptoms and Quality of Life. Chest 2024; 165:785-799. [PMID: 37979717 PMCID: PMC11026170 DOI: 10.1016/j.chest.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/06/2023] [Accepted: 11/11/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Therapeutic-dose heparin decreased days requiring organ support in noncritically ill patients hospitalized for COVID-19, but its impact on persistent symptoms or quality of life (QOL) is unclear. RESEARCH QUESTION In the Accelerating COVID-19 Therapeutic Interventions and Vaccines 4 ACUTE (ACTIV-4a) trial, was randomization of patients hospitalized for COVID-19 illness to therapeutic-dose vs prophylactic heparin associated with fewer symptoms and better QOL at 90 days? STUDY DESIGN AND METHODS This was an open-label randomized controlled trial at 34 hospitals in the United States and Spain. A total of 727 noncritically ill patients hospitalized for COVID-19 from September 2020 to June 2021 were randomized to therapeutic-dose vs prophylactic heparin. Only patients with 90-day data on symptoms and QOL were analyzed. We ascertained symptoms and QOL by the EQ-5D-5L at 90-day follow-up in a preplanned analysis for the ACTIV-4a trial. Individual domains assessed by the EQ-5D-5L included mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Univariate and multivariate analyses were performed. RESULTS Among 571 patients, 288 (50.4%) reported at least one symptom. Among 410 patients, 148 (36.1%) reported moderate to severe impairment in one or more domains of the EQ-5D-5L. The presence of 90-day symptoms was associated with moderate-severe impairment in the EQ-5D-5L domains of mobility (adjusted OR [aOR], 2.37; 95% CI, 1.22-4.59), usual activities (aOR, 3.66; 95% CI, 1.75-7.65), pain (aOR, 2.43; 95% CI, 1.43-4.12), and anxiety (aOR, 4.32; 95% CI, 2.06-9.02), compared with patients reporting no symptoms There were no differences in symptoms or in the overall EQ-5D-5L index score between treatment groups. Therapeutic-dose heparin was associated with less moderate-severe impairment in all physical functioning domains (mobility, self-care, usual activities) but was independently significant only in the self-care domain (aOR, 0.32; 95% CI, 0.11-0.96). INTERPRETATION In a randomized controlled trial of hospitalized noncritically ill patients with COVID-19, therapeutic-dose heparin was associated with less severe impairment in the self-care domain of EQ-5D-5L. However, this type of impairment was uncommon, affecting 23 individuals. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT04505774; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
| | | | - Joshua Froess
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | | | - Vidya Venugopal
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Yu-Hsuan Lai
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | | | - Steven Y Chang
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christos Colovos
- University of Vermont Larner College of Medicine, Burlington, VT
| | - Faraaz Shah
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada; McGill University Health Centre, Montreal, QC, Canada
| | - Manila Gaddh
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | | | | | - Lana Wahid
- Duke University School of Medicine, Durham, NC
| | | | | | | | - Eric Leifer
- National Heart, Lung, and Blood Institute, Bethesda, MD
| | - David T Huang
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Matthew D Neal
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Mary Cushman
- University of Vermont Larner College of Medicine, Burlington, VT
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5
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van Sleeuwen D, Zegers M, Ramjith J, Cruijsberg JK, Simons KS, van Bommel D, Burgers-Bonthuis D, Koeter J, Bisschops LLA, Janssen I, Rettig TCD, van der Hoeven JG, van de Laar FA, van den Boogaard M. Prediction of Long-Term Physical, Mental, and Cognitive Problems Following Critical Illness: Development and External Validation of the PROSPECT Prediction Model. Crit Care Med 2024; 52:200-209. [PMID: 38099732 PMCID: PMC10793772 DOI: 10.1097/ccm.0000000000006073] [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: 01/19/2024]
Abstract
OBJECTIVES ICU survivors often suffer from long-lasting physical, mental, and cognitive health problems after hospital discharge. As several interventions that treat or prevent these problems already start during ICU stay, patients at high risk should be identified early. This study aimed to develop a model for early prediction of post-ICU health problems within 48 hours after ICU admission. DESIGN Prospective cohort study in seven Dutch ICUs. SETTING/PATIENTS ICU patients older than 16 years and admitted for greater than or equal to 12 hours between July 2016 and March 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Outcomes were physical problems (fatigue or ≥ 3 new physical symptoms), mental problems (anxiety, depression, or post-traumatic stress disorder), and cognitive impairment. Patient record data and questionnaire data were collected at ICU admission, and after 3 and 12 months, of 2,476 patients. Several models predicting physical, mental, or cognitive problems and a composite score at 3 and 12 months were developed using variables collected within 48 hours after ICU admission. Based on performance and clinical feasibility, a model, PROSPECT, predicting post-ICU health problems at 3 months was chosen, including the predictors of chronic obstructive pulmonary disease, admission type, expected length of ICU stay greater than or equal to 2 days, and preadmission anxiety and fatigue. Internal validation using bootstrapping on data of the largest hospital ( n = 1,244) yielded a C -statistic of 0.73 (95% CI, 0.70-0.76). External validation was performed on data ( n = 864) from the other six hospitals with a C -statistic of 0.77 (95% CI, 0.73-0.80). CONCLUSIONS The developed and externally validated PROSPECT model can be used within 48 hours after ICU admission for identifying patients with an increased risk of post-ICU problems 3 months after ICU admission. Timely preventive interventions starting during ICU admission and follow-up care can prevent or mitigate post-ICU problems in these high-risk patients.
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Affiliation(s)
- Dries van Sleeuwen
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Zegers
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jordache Ramjith
- Department for Health Evidence, Biostatistics Research Group, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Koen S Simons
- Department of Intensive Care Medicine, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Daniëlle van Bommel
- Department of Intensive Care Medicine, Bernhoven Hospital, Uden, The Netherlands
| | | | - Julia Koeter
- Department of Intensive Care Medicine, CWZ, Nijmegen, The Netherlands
| | - Laurens L A Bisschops
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge Janssen
- Department of Intensive Care Medicine, Maasziekenhuis, Boxmeer, The Netherlands
| | - Thijs C D Rettig
- Department of Anesthesiology, Intensive Care Medicine, and Pain Medicine, Amphia Hospital, Breda, The Netherlands
| | | | - Floris A van de Laar
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark van den Boogaard
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Munroe ES, Hyzy RC, Semler MW, Shankar-Hari M, Young PJ, Zampieri FG, Prescott HC. Evolving Management Practices for Early Sepsis-induced Hypoperfusion: A Narrative Review. Am J Respir Crit Care Med 2023; 207:1283-1299. [PMID: 36812500 PMCID: PMC10595457 DOI: 10.1164/rccm.202209-1831ci] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/22/2023] [Indexed: 02/24/2023] Open
Abstract
Sepsis causes significant morbidity and mortality worldwide. Resuscitation is a cornerstone of management. This review covers five areas of evolving practice in the management of early sepsis-induced hypoperfusion: fluid resuscitation volume, timing of vasopressor initiation, resuscitation targets, route of vasopressor administration, and use of invasive blood pressure monitoring. For each topic, we review the seminal evidence, discuss the evolution of practice over time, and highlight questions for additional research. Intravenous fluids are a core component of early sepsis resuscitation. However, with growing concerns about the harms of fluid, practice is evolving toward smaller-volume resuscitation, which is often paired with earlier vasopressor initiation. Large trials of fluid-restrictive, vasopressor-early strategies are providing more information about the safety and potential benefit of these approaches. Lowering blood pressure targets is a means to prevent fluid overload and reduce exposure to vasopressors; mean arterial pressure targets of 60-65 mm Hg appear to be safe, at least in older patients. With the trend toward earlier vasopressor initiation, the need for central administration of vasopressors has been questioned, and peripheral vasopressor use is increasing, although it is not universally accepted. Similarly, although guidelines suggest the use of invasive blood pressure monitoring with arterial catheters in patients receiving vasopressors, blood pressure cuffs are less invasive and often sufficient. Overall, the management of early sepsis-induced hypoperfusion is evolving toward fluid-sparing and less-invasive strategies. However, many questions remain, and additional data are needed to further optimize our approach to resuscitation.
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Affiliation(s)
- Elizabeth S. Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Robert C. Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manu Shankar-Hari
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, United Kingdom
- Department of Intensive Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Paul J. Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Fernando G. Zampieri
- Hospital do Coração (HCor) Research Institute, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; and
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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7
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Sturgill JL, Mayer KP, Kalema AG, Dave K, Mora S, Kalantar A, Carter DJ, Montgomery-Yates AA, Morris PE. Post-intensive care syndrome and pulmonary fibrosis in patients surviving ARDS-pneumonia of COVID-19 and non-COVID-19 etiologies. Sci Rep 2023; 13:6554. [PMID: 37085548 PMCID: PMC10119831 DOI: 10.1038/s41598-023-32699-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 03/31/2023] [Indexed: 04/23/2023] Open
Abstract
The purpose was to examine patient-centered outcomes and the occurrence of lung fibrotic changes on Chest computed tomography (CT) imaging following pneumonia-related acute respiratory distress syndrome (ARDS). We sought to investigate outpatient clinic chest CT imaging in survivors of COVID19-related ARDS and non-COVID-related ARDS, to determine group differences and explore relationships between lung fibrotic changes and functional outcomes. A retrospective practice analysis of electronic health records at an ICU Recovery Clinic in a tertiary academic medical center was performed in adult patients surviving ARDS due to COVID-19 and non-COVID etiologies. Ninety-four patients with mean age 53 ± 13 and 51% male were included (n = 64 COVID-19 and n = 30 non-COVID groups). There were no differences for age, sex, hospital length of stay, ICU length of stay, mechanical ventilation duration, or sequential organ failure assessment (SOFA) scores between the two groups. Fibrotic changes visualized on CT imaging occurred in a higher proportion of COVID-19 survivors (70%) compared to the non-COVID group (43%, p < 0.001). Across both groups, patients with fibrotic changes (n = 58) were older, had a lower BMI, longer hospital and ICU LOS, lower mean RASS scores, longer total duration of supplemental oxygen. While not statistically different, patients with fibrotic changes did have reduced respiratory function, worse performance on the six-minute walk test, and had high occurrences of anxiety, depression, emotional distress, and mild cognitive impairment regardless of initial presenting diagnosis. Patients surviving pneumonia-ARDS are at high risk of impairments in physical, emotional, and cognitive health related to Post-Intensive Care Syndrome. Of clinical importance, pulmonary fibrotic changes on chest CT occurred in a higher proportion in COVID-ARDS group; however, no functional differences were measured in spirometry or physical assessments at ICU follow-up. Whether COVID infection imparts a unique recovery is not evident from these data but suggest that long-term follow up is necessary for all survivors of ARDS.
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Affiliation(s)
- Jamie L Sturgill
- Department of Microbiology, Immunology, and Molecular Genetics College of Medicine, University of Kentucky, Lexington, KY, USA
- Kentucky Research Alliance for Lung Disease, Lexington, KY, USA
| | - Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, KY, USA
- Kentucky Research Alliance for Lung Disease, Lexington, KY, USA
| | - Anna G Kalema
- Division of Pulmonary, Critical Care, and Sleep Medicine College of Medicine, Department of Internal Medicine, University of Kentucky, 740 South Limestone Street, Lexington, KY, L54340536, USA.
- Kentucky Research Alliance for Lung Disease, Lexington, KY, USA.
| | - Kinjal Dave
- Division of Pulmonary, Critical Care, and Sleep Medicine College of Medicine, Department of Internal Medicine, University of Kentucky, 740 South Limestone Street, Lexington, KY, L54340536, USA
- Kentucky Research Alliance for Lung Disease, Lexington, KY, USA
| | - Stephanie Mora
- College of Pharmacy, University of Kentucky, Lexington, KY, USA
- Kentucky Research Alliance for Lung Disease, Lexington, KY, USA
| | - Alborz Kalantar
- Department of Microbiology, Immunology, and Molecular Genetics College of Medicine, University of Kentucky, Lexington, KY, USA
- Kentucky Research Alliance for Lung Disease, Lexington, KY, USA
| | - David J Carter
- Division of Pulmonary, Critical Care, and Sleep Medicine College of Medicine, Department of Internal Medicine, University of Kentucky, 740 South Limestone Street, Lexington, KY, L54340536, USA
- Kentucky Research Alliance for Lung Disease, Lexington, KY, USA
| | - Ashley A Montgomery-Yates
- Division of Pulmonary, Critical Care, and Sleep Medicine College of Medicine, Department of Internal Medicine, University of Kentucky, 740 South Limestone Street, Lexington, KY, L54340536, USA
- Kentucky Research Alliance for Lung Disease, Lexington, KY, USA
| | - Peter E Morris
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Birmingham, Birmingham, AL, USA
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8
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Endo Y, Miyasho T, Endo K, Kawamura Y, Miyoshi K, Takegawa R, Tagami T, Becker LB, Hayashida K. Diagnostic value of transpulmonary thermodilution measurements for acute respiratory distress syndrome in a pig model of septic shock. J Transl Med 2022; 20:617. [PMID: 36564822 PMCID: PMC9789654 DOI: 10.1186/s12967-022-03793-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND No direct approach assessing pulmonary vascular permeability exists in the current therapeutic strategy for patients with acute respiratory distress syndrome (ARDS). Transpulmonary thermodilution measures hemodynamic parameters such as pulmonary vascular permeability index and extravascular lung water, enabling clinicians to assess ARDS severity. The aim of this study is to explore a precise transpulmonary thermodilution-based criteria for quantifying the severity of lung injury using a clinically relevant septic-ARDS pig model. METHODS Thirteen female pigs (weight: 31 ± 2 kg) were intubated, mechanically ventilated under anesthesia, and either assigned to septic shock-induced ARDS or control group. To confirm the development of ARDS, we performed computed tomography (CT) imaging in randomly selected animals. The pulmonary vascular permeability index, extravascular lung water, and other hemodynamic parameters were consecutively measured during the development of septic lung injury. Lung status was categorized as normal (partial pressure of oxygen/fraction of inspired oxygen ≥ 400), or injured at different degrees: pre-ARDS (300-400), mild-to-moderate ARDS (100-300), or severe ARDS (< 100). We also measured serum inflammatory cytokines and high mobility group box 1 levels during the experiment to explore the relationship of the pulmonary vascular permeability index with these inflammatory markers. RESULTS Using CT image, we verified that animals subjected to ARDS presented an extent of consolidation in bilateral gravitationally dependent gradient that expands over time, with diffuse ground-glass opacification. Further, the post-mortem histopathological analysis for lung tissue identified the key features of diffuse alveolar damage in all animals subjected to ARDS. Both pulmonary vascular permeability index and extravascular lung water increased significantly, according to disease severity. Receiver operating characteristic analysis demonstrated that a cut-off value of 3.9 for the permeability index provided optimal sensitivity and specificity for predicting severe ARDS (area under the curve: 0.99, 95% confidence interval, 0.98-1.00; sensitivity = 100%, and specificity = 92.5%). The pulmonary vascular permeability index was superior in its diagnostic value than extravascular lung water. Furthermore, the pulmonary vascular permeability index was significantly associated with multiple parameters reflecting clinicopathological changes in animals with ARDS. CONCLUSION The pulmonary vascular permeability index is an effective indicator to measure septic ARDS severity.
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Affiliation(s)
- Yusuke Endo
- grid.416477.70000 0001 2168 3646The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY 11030 USA ,grid.412658.c0000 0001 0674 6856School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido Japan
| | - Taku Miyasho
- grid.412658.c0000 0001 0674 6856School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido Japan
| | - Kanako Endo
- grid.416477.70000 0001 2168 3646The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY 11030 USA
| | - Yoshio Kawamura
- grid.412658.c0000 0001 0674 6856School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido Japan
| | - Kenjiro Miyoshi
- grid.412658.c0000 0001 0674 6856School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido Japan
| | - Ryosuke Takegawa
- grid.416477.70000 0001 2168 3646The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY 11030 USA
| | - Takashi Tagami
- grid.459842.60000 0004 0406 9101Department of Emergency Medicine and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kawasaki, Kanagawa Japan
| | - Lance B. Becker
- grid.416477.70000 0001 2168 3646The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY 11030 USA ,grid.512756.20000 0004 0370 4759Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
| | - Kei Hayashida
- grid.416477.70000 0001 2168 3646The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY 11030 USA ,grid.512756.20000 0004 0370 4759Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA ,grid.416477.70000 0001 2168 3646Department of Emergency Medicine, South Shore University Hospital, Northwell Health, Bay Shore, NY USA
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9
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Mart MF, Semler MW, Bernard G, Casey JD, Ely EW, Freundlich R, Jackson JC, Kiehl A, Jenkins C, Wang G, Lindsell C, Bryant P, Rice TW, Self WH, Stollings J, Wanderer JP, Wang L, Han JH. Cognitive Outcomes in the Pragmatic Investigation of optima L Oxygen Targets (CO-PILOT) trial: protocol and statistical analysis plan. BMJ Open 2022; 12:e064517. [PMID: 36319061 PMCID: PMC9628689 DOI: 10.1136/bmjopen-2022-064517] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/05/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Long-term cognitive impairment is one of the most common complications of critical illness among survivors who receive mechanical ventilation. Recommended oxygen targets during mechanical ventilation vary among international guidelines. Different oxygen targets during mechanical ventilation have the potential to alter long-term cognitive function due to cerebral hypoxemia or hyperoxemia. Whether higher, intermediate or lower SpO2 targets are associated with better cognitive function at 12-month follow-up is unknown. METHODS AND ANALYSIS The Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial is an ongoing pragmatic, cluster-randomised, cluster-crossover trial comparing the effect of a higher SpO2 target (target 98%, goal range 96%-100%), an intermediate SpO2 target (target 94%, goal range 92%-96%) and a lower SpO2 target (target 90%, goal range 88%-92%) on clinical outcomes in mechanically ventilated patients admitted to the medical intensive care unit at a single centre in the USA. For this ancillary study of long-term Cognitive Outcomes (CO-PILOT), survivors of critical illness who are in the PILOT trial and who do not meet exclusion criteria for CO-PILOT are approached for consent. The anticipated number of patients for whom assessment of long-term cognition will be performed in CO-PILOT is 612 patients over 36 months of enrolment. Cognitive, functional and quality of life assessments are assessed via telephone interview at approximately 12 months after enrolment in PILOT. The primary outcome of CO-PILOT is the telephone version of the Montreal Cognitive Assessment. A subset of patients will also complete a comprehensive neuropsychological telephone battery to better characterise the cognitive domains affected. ETHICS AND DISSEMINATION The CO-PILOT ancillary study was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.
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Affiliation(s)
- Matthew F Mart
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gordon Bernard
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - E Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Robert Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James C Jackson
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Amy Kiehl
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Cathy Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Guanchao Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patsy Bryant
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joanna Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin Ho Han
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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10
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Kaslow SR, Reimer JA, Pinezich MR, Hudock MR, Chen P, Morris MG, Kain ML, Leb JS, Ruzal-Shapiro CB, Marboe CC, Bacchetta M, Dorrello NV, Vunjak-Novakovic G. A clinically relevant model of acute respiratory distress syndrome in human-size swine. Dis Model Mech 2022; 15:dmm049603. [PMID: 35976034 PMCID: PMC9586570 DOI: 10.1242/dmm.049603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/10/2022] [Indexed: 11/20/2022] Open
Abstract
Despite over 30 years of intensive research for targeted therapies, treatment of acute respiratory distress syndrome (ARDS) remains supportive in nature. With mortality upwards of 30%, a high-fidelity pre-clinical model of ARDS, on which to test novel therapeutics, is urgently needed. We used the Yorkshire breed of swine to induce a reproducible model of ARDS in human-sized swine to allow the study of new therapeutics, from both mechanistic and clinical standpoints. For this, animals were anesthetized, intubated and mechanically ventilated, and pH-standardized gastric contents were delivered bronchoscopically, followed by intravenous infusion of Escherichia coli-derived lipopolysaccharide. Once the ratio of arterial oxygen partial pressure (PaO2) to fractional inspired oxygen (FIO2) had decreased to <150, the animals received standard ARDS treatment for up to 48 h. All swine developed moderate to severe ARDS. Chest radiographs taken at regular intervals showed significantly worse lung edema after induction of ARDS. Quantitative scoring of lung injury demonstrated time-dependent increases in interstitial and alveolar edema, neutrophil infiltration, and mild to moderate alveolar membrane thickening. This pre-clinical model of ARDS in human-sized swine recapitulates the clinical, radiographic and histopathologic manifestations of ARDS, providing a tool to study therapies for this highly morbid lung disease.
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Affiliation(s)
- Sarah R. Kaslow
- Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
| | - Jonathan A. Reimer
- Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
- Department of Surgery, Mount Sinai Hospital, Chicago, IL 60608, USA
| | - Meghan R. Pinezich
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
| | - Maria R. Hudock
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
- Vagelos College of Physicians and Surgeons, Columbia University Medical Center, New York, NY 10032, USA
| | - Panpan Chen
- Department of Surgery, Columbia University Medical Center, New York, NY 10032, USA
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
| | - Mariya G. Morris
- Institute of Comparative Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Mandy L. Kain
- Institute of Comparative Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Jay S. Leb
- Department of Radiology, Columbia University Medical Center, New York, NY 10032, USA
| | | | - Charles C. Marboe
- Department of Pathology, Columbia University Medical Center, New York, NY 10032, USA
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - N. Valerio Dorrello
- Department of Pediatrics, Columbia University Medical Center, New York, NY 10032, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
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11
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Kulkarni HS, Lee JS, Downey GP, Matute-Bello G. Reply: Experimental Acute Lung Injury in Animals: With Age Comes Knowledge. Am J Respir Cell Mol Biol 2022; 67:267. [PMID: 35561309 PMCID: PMC9348566 DOI: 10.1165/rcmb.2022-0091le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hrishikesh S. Kulkarni
- Washington University School of MedicineSt. Louis, Missouri,Corresponding author (e-mail: )
| | - Janet S. Lee
- University of PittsburghPittsburgh, Pennsylvania
| | | | - Gustavo Matute-Bello
- University of WashingtonSeattle, Washington,VA Puget Sound Health Care SystemSeattle, Washington
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12
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Fazzini B, Battaglini D, Carenzo L, Pelosi P, Cecconi M, Puthucheary Z. Physical and psychological impairment in survivors with acute respiratory distress syndrome: a systematic review and meta-analysis. Br J Anaesth 2022; 129:801-814. [DOI: 10.1016/j.bja.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/11/2022] [Accepted: 08/18/2022] [Indexed: 11/26/2022] Open
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13
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Pannu SR, Haddad T, Exline M, Christman JW, Horowitz JC, Peters J, Brock G, Diaz P, Crouser ED. Rationale and design of a randomized controlled clinical trial; Titration of Oxygen Levels (TOOL) during mechanical ventilation. Contemp Clin Trials 2022; 119:106811. [PMID: 35660485 PMCID: PMC11114599 DOI: 10.1016/j.cct.2022.106811] [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] [Received: 02/06/2022] [Revised: 05/05/2022] [Accepted: 05/25/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Both hyperoxemia and hypoxemia are deleterious in critically ill patients. Targeted oxygenation is recommended to prevent both of these extremes, however this has not translated to the bedside. Hyperoxemia likely persists more than hypoxemia due to absence of immediate discernible adverse effects, cognitive biases and delay in prioritization of titration. METHODS We present the methodology for the Titration Of Oxygen Levels (TOOL) trial, an open label, randomized controlled trial of an algorithm-based FiO2 titration with electronic medical record-based automated alerts. We hypothesize that the study intervention will achieve targeted oxygenation by curbing episodes of hyperoxemia while preventing hypoxemia. In the intervention arm, electronic alerts will be used to titrate FiO2 if SpO2 is ≥94% with FiO2 levels ≥0.4 over 45 min. FiO2 will be titrated per standard practice in the control arm. This study is being carried out with deferred consent. The sample size to determine efficacy is 316 subjects, randomized in a 1:1 ratio to the intervention vs. control arm. The primary outcome is proportion of time during mechanical ventilation spent with FiO2 ≥ 0.4 and SpO2 ≥ 94%. We will also assess proportion of time during mechanical ventilation spent with SpO2 < 88%, duration of mechanical ventilation, length of ICU and hospital stay, hospital mortality, and adherence to electronic alerts as secondary outcomes. CONCLUSION This study is designed to evaluate the efficacy of a high fidelity, bioinformatics-based, electronic medical record derived electronic alert system to improve targeted oxygenation in mechanically ventilated patients by reducing excessive FiO2 exposure.
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Affiliation(s)
- Sonal R Pannu
- The Ohio State University, Division of Pulmonary, Critical Care & Sleep Medicine, Columbus, OH, United States.
| | - Tyler Haddad
- The Ohio State University, Department of Internal Medicine, Columbus, OH, United States
| | - Matthew Exline
- The Ohio State University, Division of Pulmonary, Critical Care & Sleep Medicine, Columbus, OH, United States
| | - John W Christman
- The Ohio State University, Division of Pulmonary, Critical Care & Sleep Medicine, Columbus, OH, United States
| | - Jeffrey C Horowitz
- The Ohio State University, Division of Pulmonary, Critical Care & Sleep Medicine, Columbus, OH, United States
| | - Jonathan Peters
- The Ohio State University, Department of Respiratory Therapy, Columbus, OH, United States
| | - Guy Brock
- The Ohio State University, Center for Biostatistics and Bioinformatics, Columbus, OH, United States
| | - Philip Diaz
- The Ohio State University, Division of Pulmonary, Critical Care & Sleep Medicine, Columbus, OH, United States
| | - Elliott D Crouser
- The Ohio State University, Division of Pulmonary, Critical Care & Sleep Medicine, Columbus, OH, United States
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14
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Russell DW, Casey JD, Gibbs KW, Ghamande S, Dargin JM, Vonderhaar DJ, Joffe AM, Khan A, Prekker ME, Brewer JM, Dutta S, Landsperger JS, White HD, Robison SW, Wozniak JM, Stempek S, Barnes CR, Krol OF, Arroliga AC, Lat T, Gandotra S, Gulati S, Bentov I, Walters AM, Dischert KM, Nonas S, Driver BE, Wang L, Lindsell CJ, Self WH, Rice TW, Janz DR, Semler MW. Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA 2022; 328:270-279. [PMID: 35707974 PMCID: PMC9204618 DOI: 10.1001/jama.2022.9792] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/25/2022] [Indexed: 12/12/2022]
Abstract
Importance Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain. Objective To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death. Design, Setting, and Participants This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021. Interventions Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527). Main Outcomes and Measures The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure <65 mm Hg between induction of anesthesia and 2 minutes after tracheal intubation, or cardiac arrest or death between induction of anesthesia and 1 hour after tracheal intubation). The secondary outcome was the incidence of death prior to day 28, which was censored at hospital discharge. Results Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis (median age, 62 years [IQR, 51-70 years]; 42.1% were women). Cardiovascular collapse occurred in 113 patients (21.0%) in the fluid bolus group and in 96 patients (18.2%) in the no fluid bolus group (absolute difference, 2.8% [95% CI, -2.2% to 7.7%]; P = .25). New or increased receipt of vasopressors occurred in 20.6% of patients in the fluid bolus group compared with 17.6% of patients in the no fluid bolus group, a systolic blood pressure of less than 65 mm Hg occurred in 3.9% vs 4.2%, respectively, cardiac arrest occurred in 1.7% vs 1.5%, and death occurred in 0.7% vs 0.6%. Death prior to day 28 (censored at hospital discharge) occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group (absolute difference, -1.8% [95% CI, -7.9% to 4.3%]; P = .55). Conclusions and Relevance Among critically ill adults undergoing tracheal intubation, administration of an intravenous fluid bolus compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse. Trial Registration ClinicalTrials.gov Identifier: NCT03787732.
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Affiliation(s)
- Derek W. Russell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
- Pulmonary Section, Birmingham Veteran’s Affairs Medical Center, Birmingham, Alabama
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kevin W. Gibbs
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Shekhar Ghamande
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - James M. Dargin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Derek J. Vonderhaar
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
| | - Aaron M. Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Akram Khan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Joseph M. Brewer
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Simanta Dutta
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Janna S. Landsperger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Heath D. White
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Sarah W. Robison
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Joanne M. Wozniak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Susan Stempek
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | | | - Olivia F. Krol
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Alejandro C. Arroliga
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Tasnim Lat
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Sheetal Gandotra
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Swati Gulati
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Kevin M. Dischert
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
| | - Stephanie Nonas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Brian E. Driver
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Li Wang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David R. Janz
- University Medical Center New Orleans, New Orleans, Louisiana
- Section of Pulmonary/Critical Care and Allergy/Immunology, Department of Medicine, Louisiana State University School of Medicine, New Orleans
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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15
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Hanley C, Giacomini C, Brennan A, McNicholas B, Laffey JG. Insights Regarding the Berlin Definition of ARDS from Prospective Observational Studies. Semin Respir Crit Care Med 2022; 43:379-389. [PMID: 35679873 DOI: 10.1055/s-0042-1744306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The definition of acute respiratory distress syndrome (ARDS), has evolved since it was first described in 1967 by Ashbaugh and Petty to the current "Berlin" definition of ARDS developed in 2012 by an expert panel, that provided clarification on the definition of "acute," and on the cardiac failure criteria. It expanded the definition to include patients receiving non-invasive ventilation, and removed the term "acute lung injury" and added a requirement of patients to be receiving a minimum 5 cmH2O expiratory pressure.Since 2012, a series of observational cohort studies have generated insights into the utility and robustness of this definition. This review will examine novel insights into the epidemiology of ARDS, failures in ARDS diagnosis, the role of lung imaging in ARDS, the novel ARDS cohort that is not invasively ventilated, lung compliance profiles in patients with ARDS, sex differences that exist in ARDS management and outcomes, the progression of ARDS following initial diagnosis, and the clinical profile and outcomes of confirmed versus resolved ARDS. Furthermore, we will discuss studies that challenge the utility of distinguishing ARDS from other causes of acute hypoxemic respiratory failure (AHRF) and identify issues that may need to be addressed in a revised definition.
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Affiliation(s)
- Ciara Hanley
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Camilla Giacomini
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland
| | - Aoife Brennan
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Department of Anaesthesia and Intensive Care medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute, National University of Ireland, Galway, Ireland
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16
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Grolleau F, Porcher R, Barbar S, Hajage D, Bourredjem A, Quenot JP, Dreyfuss D, Gaudry S. Personalization of renal replacement therapy initiation: a secondary analysis of the AKIKI and IDEAL-ICU trials. Crit Care 2022; 26:64. [PMID: 35313942 PMCID: PMC8939225 DOI: 10.1186/s13054-022-03936-y] [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: 01/07/2022] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background Trials comparing early and delayed strategies of renal replacement therapy in patients with severe acute kidney injury may have missed differences in survival as a result of mixing together patients at heterogeneous levels of risks. Our aim was to evaluate the heterogeneity of treatment effect on 60-day mortality from an early vs a delayed strategy across levels of risk for renal replacement therapy initiation under a delayed strategy. Methods We used data from the AKIKI, and IDEAL-ICU randomized controlled trials to develop a multivariable logistic regression model for renal replacement therapy initiation within 48 h after allocation to a delayed strategy. We then used an interaction with spline terms in a Cox model to estimate treatment effects across the predicted risks of RRT initiation. Results We analyzed data from 1107 patients (619 and 488 in the AKIKI and IDEAL-ICU trial respectively). In the pooled sample, we found evidence for heterogeneous treatment effects (P = 0.023). Patients at an intermediate-high risk of renal replacement therapy initiation within 48 h may have benefited from an early strategy (absolute risk difference, − 14%; 95% confidence interval, − 27% to − 1%). For other patients, we found no evidence of benefit from an early strategy of renal replacement therapy initiation but a trend for harm (absolute risk difference, 8%; 95% confidence interval, − 5% to 21% in patients at intermediate-low risk). Conclusions We have identified a clinically sound heterogeneity of treatment effect of an early vs a delayed strategy of renal replacement therapy initiation that may reflect varying degrees of kidney demand-capacity mismatch. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03936-y.
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Affiliation(s)
- François Grolleau
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM U1153), French National Research Institute for Agriculture, Food, and Environment (INRAE), Paris, France.
| | - Raphaël Porcher
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM U1153), French National Research Institute for Agriculture, Food, and Environment (INRAE), Paris, France
| | - Saber Barbar
- Intensive Care Department, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - David Hajage
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie, Sorbonne Université, Paris, France
| | - Abderrahmane Bourredjem
- Clinical Epidemiology Unit, INSERM CIC1432, Dijon, and Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon Bourgogne University Hospital, Dijon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Lipness Team, INSERM Research Center, LNC-UMR1231 and LabEx LipSTIC, and INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Didier Dreyfuss
- Université de Paris, Service de Médecine Intensive-Réanimation, Hôpital Louis Mourier, AP-HP and INSERM, UMR S1155 "Common and Rare Kidney Diseases: From Molecular Events To Precision Medicine", Sorbonne Université, Paris, France
| | - Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, APHP, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, French National Institute of Health and Medical Research (INSERM), Common and Rare kidney Diseases (CORAKID), Hôpital Tenon, Paris, France
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Christon LM, Smith PJ. Psychosocial Evaluation for Lung Transplantation: an Empirically Informed Update. CURRENT TRANSPLANTATION REPORTS 2022. [DOI: 10.1007/s40472-022-00360-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Kulkarni HS, Lee JS, Bastarache JA, Kuebler WM, Downey GP, Albaiceta GM, Altemeier WA, Artigas A, Bates JHT, Calfee CS, Dela Cruz CS, Dickson RP, Englert JA, Everitt JI, Fessler MB, Gelman AE, Gowdy KM, Groshong SD, Herold S, Homer RJ, Horowitz JC, Hsia CCW, Kurahashi K, Laubach VE, Looney MR, Lucas R, Mangalmurti NS, Manicone AM, Martin TR, Matalon S, Matthay MA, McAuley DF, McGrath-Morrow SA, Mizgerd JP, Montgomery SA, Moore BB, Noël A, Perlman CE, Reilly JP, Schmidt EP, Skerrett SJ, Suber TL, Summers C, Suratt BT, Takata M, Tuder R, Uhlig S, Witzenrath M, Zemans RL, Matute-Bello G. Update on the Features and Measurements of Experimental Acute Lung Injury in Animals: An Official American Thoracic Society Workshop Report. Am J Respir Cell Mol Biol 2022; 66:e1-e14. [PMID: 35103557 PMCID: PMC8845128 DOI: 10.1165/rcmb.2021-0531st] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Advancements in methods, technology, and our understanding of the pathobiology of lung injury have created the need to update the definition of experimental acute lung injury (ALI). We queried 50 participants with expertise in ALI and acute respiratory distress syndrome using a Delphi method composed of a series of electronic surveys and a virtual workshop. We propose that ALI presents as a "multidimensional entity" characterized by four "domains" that reflect the key pathophysiologic features and underlying biology of human acute respiratory distress syndrome. These domains are 1) histological evidence of tissue injury, 2) alteration of the alveolar-capillary barrier, 3) presence of an inflammatory response, and 4) physiologic dysfunction. For each domain, we present "relevant measurements," defined as those proposed by at least 30% of respondents. We propose that experimental ALI encompasses a continuum of models ranging from those focusing on gaining specific mechanistic insights to those primarily concerned with preclinical testing of novel therapeutics or interventions. We suggest that mechanistic studies may justifiably focus on a single domain of lung injury, but models must document alterations of at least three of the four domains to qualify as "experimental ALI." Finally, we propose that a time criterion defining "acute" in ALI remains relevant, but the actual time may vary based on the specific model and the aspect of injury being modeled. The continuum concept of ALI increases the flexibility and applicability of the definition to multiple models while increasing the likelihood of translating preclinical findings to critically ill patients.
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Turnbull AE, Ji H, Dinglas VD, Wu AW, Mendez-Tellez PA, Himmelfarb CD, Shanholtz CB, Hosey MM, Hopkins RO, Needham DM. Understanding Patients' Perceived Health After Critical Illness: Analysis of Two Prospective, Longitudinal Studies of ARDS Survivors. Chest 2022; 161:407-417. [PMID: 34419426 PMCID: PMC8941599 DOI: 10.1016/j.chest.2021.07.2177] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/15/2021] [Accepted: 07/31/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Perceived health is one of the strongest determinants of subjective well-being, but it has received little attention among survivors of ARDS. RESEARCH QUESTION How well do self-reported measures of physical, emotional, and social functioning predict perceived overall health (measured using the EQ-5D visual analog scale [EQ-5D-VAS]) among adult survivors of ARDS? Are demographic features, comorbidity, or severity of illness correlated with perceived health after controlling for self-reported functioning? STUDY DESIGN AND METHODS We analyzed the ARDSNet Long Term Outcomes Study (ALTOS) and Improving Care of Acute Lung Injury Patients (ICAP) Study, two longitudinal cohorts with a total of 823 survivors from 44 US hospitals, which prospectively assessed survivors at 6 and 12 months after ARDS. Perceived health, evaluated using the EQ-5D-VAS, was predicted using ridge regression and self-reported measures of physical, emotional, and social functioning. The difference between observed and predicted perceived health was termed perspective deviation (PD). Correlations between PD and demographics, comorbidities, and severity of illness were explored. RESULTS The correlation between observed and predicted EQ-5D-VAS scores ranged from 0.68 to 0.73 across the two cohorts and time points. PD ranged from -80 to +34 and was more than the minimum clinically important difference for 52% to 55% of survivors. Neither demographic features, comorbidity, nor severity of illness were correlated strongly with PD, with |r| < 0.25 for all continuous variables in both cohorts and time points. The correlation between PD at 6- and 12-month assessments was weak (ALTOS: r = 0.22, P < .001; ICAP: r = 0.20, P = .02). INTERPRETATION About half of survivors of ARDS showed clinically important differences in actual perceived health vs predicted perceived health based on self-reported measures of functioning. Survivors of ARDS demographic features, comorbidities, and severity of illness were correlated only weakly with perceived health after controlling for measures of perceived functioning, highlighting the challenge of predicting how individual patients will respond psychologically to new impairments after critical illness.
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Affiliation(s)
- Alison E Turnbull
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD.
| | - Hongkai Ji
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Albert W Wu
- Center for Health Services and Outcomes Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Division of General Internal Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Pedro A Mendez-Tellez
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Cheryl Dennison Himmelfarb
- Office for Science and Innovation, Johns Hopkins School of Nursing, Johns Hopkins University, Baltimore, MD
| | - Carl B Shanholtz
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD
| | - Megan M Hosey
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT; Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD; Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD
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20
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Parker AM, Brigham E, Connolly B, McPeake J, Agranovich AV, Kenes MT, Casey K, Reynolds C, Schmidt KFR, Kim SY, Kaplin A, Sevin CM, Brodsky MB, Turnbull AE. Addressing the post-acute sequelae of SARS-CoV-2 infection: a multidisciplinary model of care. THE LANCET. RESPIRATORY MEDICINE 2021; 9:1328-1341. [PMID: 34678213 PMCID: PMC8525917 DOI: 10.1016/s2213-2600(21)00385-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/05/2021] [Accepted: 08/10/2021] [Indexed: 11/24/2022]
Abstract
As of July 31, 2021, SARS-CoV-2 had infected almost 200 million people worldwide. The growing burden of survivorship is substantial in terms of the complexity of long-term health effects and the number of people affected. Persistent symptoms have been reported in patients with both mild and severe acute COVID-19, including those admitted to the intensive care unit (ICU). Early reports on the post-acute sequelae of SARS-CoV-2 infection (PASC) indicate that fatigue, dyspnoea, cough, headache, loss of taste or smell, and cognitive or mental health impairments are among the most common symptoms. These complex, multifactorial impairments across the domains of physical, cognitive, and mental health require a coordinated, multidisciplinary approach to management. Decades of research on the multifaceted needs of and models of care for patients with post-intensive care syndrome provide a framework for the development of PASC clinics to address the immediate needs of both hospitalised and non-hospitalised survivors of COVID-19. Such clinics could also provide a platform for rigorous research into the natural history of PASC and the potential benefits of therapeutic interventions.
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Affiliation(s)
- Ann M Parker
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Emily Brigham
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bronwen Connolly
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK; Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK; Centre for Human and Applied Physiological Sciences, King's College London, London, UK; Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Joanne McPeake
- Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Anna V Agranovich
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael T Kenes
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Kelly Casey
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cynthia Reynolds
- Sydney and Lois Eskenazi Health Critical Care Recovery Center, Indianapolis, IN, USA
| | - Konrad F R Schmidt
- Institutes of General Practice & Family Medicine, Charité University Medicine, Berlin, Germany; Institute of General Practice & Family Medicine, Jena University Hospital, Jena, Germany
| | - Soo Yeon Kim
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Adam Kaplin
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Carla M Sevin
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Martin B Brodsky
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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21
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Ward DS, Absalom AR, Aitken LM, Balas MC, Brown DL, Burry L, Colantuoni E, Coursin D, Devlin JW, Dexter F, Dworkin RH, Egan TD, Elliott D, Egerod I, Flood P, Fraser GL, Girard TD, Gozal D, Hopkins RO, Kress J, Maze M, Needham DM, Pandharipande P, Riker R, Sessler DI, Shafer SL, Shehabi Y, Spies C, Sun LS, Tung A, Urman RD. Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III. Crit Care Med 2021; 49:1684-1693. [PMID: 33938718 PMCID: PMC8439670 DOI: 10.1097/ccm.0000000000005049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.
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Affiliation(s)
- Denham S Ward
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anthony R Absalom
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Leanne M Aitken
- School of Health Sciences, University of London, London, United Kingdom
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia
| | - Michele C Balas
- Center of Healthy Aging, Self-Management, and Complex Care, The Ohio State University, College of Nursing, Columbus, OH
| | | | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Douglas Coursin
- Departments of Anesthesiology and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Talmage D Egan
- Department of Anesthesiology, University of Utah, Salt Lake City, UT
| | - Doug Elliott
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Ingrid Egerod
- Intensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pamela Flood
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA
| | - Gilles L Fraser
- Department of Medicine, Tufts University School of Medicine, Maine Medical Center, Portland, ME
| | - Timothy D Girard
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - David Gozal
- Division of Anesthesiology and CCM, Hadassah Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Ramona O Hopkins
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT
| | - John Kress
- Department of Medicine, Section of Pulmonary and Critical Care, The University of Chicago, Chicago, IL
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Pratik Pandharipande
- Department of Anesthesiology and the Critical Illness, Vanderbilt University Medical Center, Nashville, TN
| | - Richard Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Steven L Shafer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences - Department of Intensive Care Medicine - Critical Care Research, Melbourne, VIC, Australia
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Charité Mitte & Campus Virchow-Klinikum, Berlin, Germany
| | - Lena S Sun
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - Avery Tung
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Lane T, Sottile PD, Peterson R, Jin Y, Moss M. Significant Variability in Surrogate Informed Consent Rates in ARDS and Prevention and Early Treatment of Acute Lung Injury Network Multicenter Trials. Chest 2021; 161:1306-1309. [PMID: 34543666 PMCID: PMC8552548 DOI: 10.1016/j.chest.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/01/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Trevor Lane
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ryan Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ying Jin
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
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Sathe NA, Zelnick LR, Mikacenic C, Morrell ED, Bhatraju PK, McNeil JB, Kosamo S, Hough CL, Liles WC, Ware LB, Wurfel MM. Identification of persistent and resolving subphenotypes of acute hypoxemic respiratory failure in two independent cohorts. Crit Care 2021; 25:336. [PMID: 34526076 PMCID: PMC8442814 DOI: 10.1186/s13054-021-03755-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Acute hypoxemic respiratory failure (HRF) is associated with high morbidity and mortality, but its heterogeneity challenges the identification of effective therapies. Defining subphenotypes with distinct prognoses or biologic features can improve therapeutic trials, but prior work has focused on ARDS, which excludes many acute HRF patients. We aimed to characterize persistent and resolving subphenotypes in the broader HRF population. METHODS In this secondary analysis of 2 independent prospective ICU cohorts, we included adults with acute HRF, defined by invasive mechanical ventilation and PaO2-to-FIO2 ratio ≤ 300 on cohort enrollment (n = 768 in the discovery cohort and n = 1715 in the validation cohort). We classified patients as persistent HRF if still requiring mechanical ventilation with PaO2-to-FIO2 ratio ≤ 300 on day 3 following ICU admission, or resolving HRF if otherwise. We estimated relative risk of 28-day hospital mortality associated with persistent HRF, compared to resolving HRF, using generalized linear models. We also estimated fold difference in circulating biomarkers of inflammation and endothelial activation on cohort enrollment among persistent HRF compared to resolving HRF. Finally, we stratified our analyses by ARDS to understand whether this was driving differences between persistent and resolving HRF. RESULTS Over 50% developed persistent HRF in both the discovery (n = 386) and validation (n = 1032) cohorts. Persistent HRF was associated with higher risk of death relative to resolving HRF in both the discovery (1.68-fold, 95% CI 1.11, 2.54) and validation cohorts (1.93-fold, 95% CI 1.50, 2.47), after adjustment for age, sex, chronic respiratory illness, and acute illness severity on enrollment (APACHE-III in discovery, APACHE-II in validation). Patients with persistent HRF displayed higher biomarkers of inflammation (interleukin-6, interleukin-8) and endothelial dysfunction (angiopoietin-2) than resolving HRF after adjustment. Only half of persistent HRF patients had ARDS, yet exhibited higher mortality and biomarkers than resolving HRF regardless of whether they qualified for ARDS. CONCLUSION Patients with persistent HRF are common and have higher mortality and elevated circulating markers of lung injury compared to resolving HRF, and yet only a subset are captured by ARDS definitions. Persistent HRF may represent a clinically important, inclusive target for future therapeutic trials in HRF.
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Affiliation(s)
- Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA.
| | - Leila R Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carmen Mikacenic
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Benaroya Research Institute, Seattle, WA, USA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
| | - J Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Susanna Kosamo
- Department of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - Catherine L Hough
- Division of Pulmonary and Critical Care, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - W Conrad Liles
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Box # 359640, Seattle, WA, 98104, USA
- Sepsis Center of Research Excellence, University of Washington, Seattle, WA, USA
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24
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Surrogate Informed Consent: A Qualitative Analysis of Surrogate Decision Makers' Perspectives. Ann Am Thorac Soc 2021; 18:1185-1190. [PMID: 33529538 DOI: 10.1513/annalsats.202007-851oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rationale: Clinical critical care research often hinges on surrogate informed consent, as patients commonly lack decision-making capacity because of their acute illness. The surrogate informed consent process has been identified as having flaws and needing improvement. A better understanding of surrogates' perspectives is required to understand and address these shortcomings and thereby improve this process. Objectives: To explore the perspectives of surrogate decision makers of critically ill, mechanically ventilated patients about being approached about having their loved one participate in hypothetical research studies. Methods: We performed semistructured qualitative interviews of surrogate decision makers of critically ill, mechanically ventilated patients, exploring their decisional needs surrounding participation in research. These interviews were recorded and transcribed verbatim. A thematic analysis of transcripts was performed with an iterative group framework using a mixed inductive and deductive approach. Results: A sample of 21 surrogate decision makers were interviewed. Thematic saturation was achieved by the consensus of the investigators. We identified trust as a unifying domain for the themes that emerged through the analytic process. Embedded within the domain of trust, two central themes became apparent: knowledge-based trust and context-based trust. Knowledge-based trust includes subthemes of logistics, accountability, and mutual respect, whereas context-based trust includes trust in the individual clinicians and trust in the hospital system. Conclusions: Our findings highlight the nuanced layers of trust central to the surrogate informed consent process. To enhance the surrogate informed consent process for participation in critical care research studies, it is crucial that researchers recognize the inherent importance of trust to ensure an effective informed consent process.
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Morelli N, Johnson NF, Cassity EP, Kalema AG, Morris PE, Montgomery-Yates AA, Mayer KP. Feasibility of Contrasting Brain Connectivity Patterns in Cognitive and Motor Cerebral Networks to Clinical Outcomes in Patients Surviving Acute Respiratory Failure: A Pilot Study. Cureus 2021; 13:e17785. [PMID: 34659996 PMCID: PMC8495532 DOI: 10.7759/cureus.17785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND There is a paucity of research regarding the feasibility and association of cerebral cortex function to patient outcomes after acute respiratory failure (ARF). PURPOSE To determine the feasibility of functional connectivity measures and examine the association of functional connectivity to a multifaceted battery of outcomes in survivors of ARF. METHODS Eight ARF patients (age:58±3.7, ICU days:10.4±8.6) completed functional magnetic resonance imaging (fMRI), cognitive, physical-function, anxiety, depression, and driving simulator tests at one month post-hospital discharge. Pearson's correlations assessed the relationship between functional connectivity within the default mode network (FPN), sensorimotor network (SMN), and frontoparietal network (FPN) to outcomes. RESULTS Low physical-function (r=0.75, p=0.03) and divided-attention (r=-0.86, p=0.03) during the driving simulator task correlated with low FPN connectivity. Low SMN connectivity demonstrated relationships to slower gait speed (r=0.82, p=0.01) and low short physical performance battery (SPPB) scores (r=0.81, p=0.01). CONCLUSIONS fMRI is feasible to assess ARF patients' post-ICU limitations, as low post-ARF brain connectivity may be linked to low physical function, providing potential development of therapeutic interventions.
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Affiliation(s)
- Nathan Morelli
- Department of Physical Therapy, High Point University, High Point, USA
| | - Nathan F Johnson
- Department of Physical Therapy, University of Kentucky, Lexington, USA
| | - Evan P Cassity
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Anna G Kalema
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Peter E Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Ashley A Montgomery-Yates
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Kentucky College of Medicine, Lexington, USA
| | - Kirby P Mayer
- Department of Physical Therapy, University of Kentucky, Lexington, USA
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Peritraumatic Stress Symptoms during Early Post-Intensive Care Unit Recovery. Ann Am Thorac Soc 2021; 18:364-367. [PMID: 32870018 PMCID: PMC7869785 DOI: 10.1513/annalsats.202005-538rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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27
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Higgins AM, Neto AS, Bailey M, Barrett J, Bellomo R, Cooper DJ, Gabbe BJ, Linke N, Myles PS, Paton M, Philpot S, Shulman M, Young M, Hodgson CL. Predictors of death and new disability after critical illness: a multicentre prospective cohort study. Intensive Care Med 2021; 47:772-781. [PMID: 34089063 DOI: 10.1007/s00134-021-06438-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/15/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE This study aimed to determine the prevalence and predictors of death or new disability following critical illness. METHODS Prospective, multicentre cohort study conducted in six metropolitan intensive care units (ICU). Participants were adults admitted to the ICU who received more than 24 h of mechanical ventilation. The primary outcome was death or new disability at 6 months, with new disability defined by a 10% increase in the WHODAS 2.0. RESULTS Of 628 patients with the primary outcome available (median age of 62 [49-71] years, 379 [61.0%] had a medical admission and 370 (58.9%) died or developed new disability by 6 months. Independent predictors of death or new disability included age [OR 1.02 (1.01-1.03), P = 0.001], higher severity of illness (APACHE III) [OR 1.02 (1.01-1.03), P < 0.001] and admission diagnosis. Compared to patients with a surgical admission diagnosis, patients with a cardiac arrest [OR (95% CI) 4.06 (1.89-8.68), P < 0.001], sepsis [OR (95% CI) 2.43 (1.32-4.47), P = 0.004], or trauma [OR (95% CI) 6.24 (3.07-12.71), P < 0.001] diagnosis had higher odds of death or new disability, while patients with a lung transplant [OR (95% CI) 0.21 (0.07-0.58), P = 0.003] diagnosis had lower odds. A model including these three variables had good calibration (Brier score 0.20) and acceptable discriminative power with an area under the receiver operating characteristic curve of 0.76 (95% CI 0.72-0.80). CONCLUSION Less than half of all patients mechanically ventilated for more than 24 h were alive and free of new disability at 6 months after admission to ICU. A model including age, illness severity and admission diagnosis has acceptable discriminative ability to predict death or new disability at 6 months.
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Affiliation(s)
- A M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - A Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - M Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - J Barrett
- Intensive Care Unit, Epworth Healthcare, Melbourne, VIC, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - R Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - D J Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - B J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - N Linke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - P S Myles
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - M Paton
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Physiotherapy, Monash Health, Melbourne, VIC, Australia
| | - S Philpot
- Intensive Care Unit, Cabrini Health, Melbourne, VIC, Australia
| | - M Shulman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - M Young
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - C L Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia. .,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia.
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Carenzo L, Protti A, Dalla Corte F, Aceto R, Iapichino G, Milani A, Santini A, Chiurazzi C, Ferrari M, Heffler E, Angelini C, Aghemo A, Ciccarelli M, Chiti A, Iwashyna TJ, Herridge MS, Cecconi M. Short-term health-related quality of life, physical function and psychological consequences of severe COVID-19. Ann Intensive Care 2021; 11:91. [PMID: 34089104 PMCID: PMC8177269 DOI: 10.1186/s13613-021-00881-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/21/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Survivors of severe COVID-19 are at risk of impaired health-related quality of life (HRQoL) and persistent physical and psychological disability after ICU and hospital discharge. The subsequent social burden is a major concern. We aimed to assess the short-term HRQoL, physical function and prevalence of post-traumatic stress symptoms of invasively mechanically ventilated COVID-19 patients treated in our ICU. METHODS Prospective, observational cohort study in a follow-up clinic. Patients completed a 6-min walking test (6MWT) to assess their cardio-pulmonary function around 2 months (early follow-up) from hospital discharge, the EQ-5D-5L questionnaire for quality of life assessment around 2 months and at 6 months from hospital discharge and an anonymous web-based Impact of Event Scale-Revised (IES-R) questionnaire for Post-Traumatic Stress symptoms at 2 months. RESULTS 47 patients attended our follow-up program, mean age 59 ± 10 years, median pre-morbid Clinical Frailty Scale (CFS) 2 [2-3]. The median distance walked in 6 min was 470 [406-516] m, 83 [67-99]% of the predicted value. Overall 1 out 3 patients and 4/18 (22%) among those with a good functional baseline prior to COVID-19 (CFS of 1 or 2) had lower (84%) than predicted 6MWT. EQ-5D-5L quality of life VAS was 80 [70-90] out of 100 at early follow-up with a slight improvement to 85 [77.5-90] at 6 months. Mobility, self-care and usual activities improved between the two timepoints, while pain/discomfort and depression/anxiety did not improve or got worse. The IES-R total score was greater than the threshold for concern of 1.6 in 27/41(66%) respondents. CONCLUSIONS Patients recovering from severe COVID-19 requiring invasive mechanical ventilation surviving hospital discharge present with early mild to moderate functional impairment, mildly reduced quality of life from hospital discharge with an overall improvement of mobility, self-care and the ability of performing usual activities, while a worsening of pain and depression/anxiety symptoms at 6 months and a large proportion of symptoms of post-traumatic distress soon after hospital discharge.
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Affiliation(s)
- Luca Carenzo
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy.
| | - Alessandro Protti
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Italy
| | - Francesca Dalla Corte
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Romina Aceto
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Giacomo Iapichino
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Angelo Milani
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Italy
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Chiara Chiurazzi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Michele Ferrari
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Enrico Heffler
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Italy.,Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Claudio Angelini
- Department of Renal Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Italy.,Department of Internal Medicine and Hepatology, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Michele Ciccarelli
- Department of Respiratory Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Italy.,Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, USA
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, Institute of Medical Science, Toronto General Research Institute, University of Toronto, Toronto, Canada
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Italy
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Kukhon FR, Festic E. Adjuvant Inhaled Corticosteroids in Community-Acquired Pneumonia: A Review Article. Med Sci (Basel) 2021; 9:34. [PMID: 34071031 PMCID: PMC8162532 DOI: 10.3390/medsci9020034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/15/2022] Open
Abstract
Community-acquired pneumonia is still a major cause of morbidity and mortality worldwide. Since the inflammatory response induced by the immune system is often a major contributor to the lung injury, it becomes reasonable to assess the potential benefit of anti-inflammatory agents in treating community-acquired pneumonia. The role of corticosteroids as adjunct anti-inflammatory agents in treating community-acquired pneumonia is still controversial. Several studies have assessed the benefit of their use in patients with community-acquired pneumonia. In most of those studies, the route of corticosteroids administration was systemic. The aim of this article is to provide a concise review of the role of corticosteroids in treating community-acquired pneumonia when administered via inhalational route, with the potential benefit of avoiding systemic side effects of corticosteroids while exerting the same anti-inflammatory effects on the lungs. Conclusion: the use of inhaled corticosteroids may be of benefit in certain patient subsets with community-acquired pneumonia. Further randomized controlled trials are needed for better determination of such patient subsets.
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Affiliation(s)
| | - Emir Festic
- Division of Pulmonary and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL 32224, USA;
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Taylor SP, Kowalkowski MA, Admon AJ. Timing Is Everything. The Importance of Alignment of Time Anchors for Observational Causal Inference Research. Ann Am Thorac Soc 2021; 18:769-772. [PMID: 33217239 PMCID: PMC8086541 DOI: 10.1513/annalsats.202009-1163vp] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/20/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - Marc A. Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina; and
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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Bodily pain in survivors of acute respiratory distress syndrome: A 1-year longitudinal follow-up study. J Psychosom Res 2021; 144:110418. [PMID: 33744745 DOI: 10.1016/j.jpsychores.2021.110418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 02/04/2021] [Accepted: 03/10/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) survivors frequently experience bodily pain during recovery after the intensive care unit. Longitudinal course, risk factors and associations with physical and neuropsychological health is lacking. METHODS We collected self-reported pain using the Short Form-36 Bodily Pain (SF-36 BP) scale, normalized for sex and age (range: 0-100; higher score = less pain), along with physical and mental health measures in a multi-center, prospective cohort of 826 ARDS survivors at 6- and 12-month follow-up. We examined baseline and ICU variables' associations with pain via separate unadjusted regression models. RESULTS Pain prevalence (SF-36 BP ≤40) was 45% and 42% at 6 and 12 months, respectively. Among 706 patients with both 6- and 12-month data, 34% reported pain at both timepoints. Pre-ARDS employment was associated with less pain at 6-months (mean difference (standard error), 5.7 (0.9), p < 0.001) and 12-months (6.3 (0.9), p < 0.001); smoking history was associated with greater pain (-5.0 (0.9), p < 0.001, and - 5.4 (1.0), p < 0.001, respectively). In-ICU opioid use was associated with greater pain (-6.3 (2.7), p = 0.02, and - 7.3 (2.8), p = 0.01, respectively). At 6 months, 174 (22%) patients reported co-occurring pain, depression and anxiety, and 227 (33%) reported co-occurring pain and impaired physical function. CONCLUSION Nearly half of ARDS survivors reported bodily pain at 6- and 12-month follow-up; one-third reported pain at both time points. Pre-ARDS unemployment, smoking history, and in-ICU opioid use may identify patients who report greater pain during recovery. Given its frequent co-occurrence, clinicians should manage both physical and neuropsychological issues when pain is reported.
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Tiba MH, McCracken BM, Leander DC, Colmenero CI, Nemzek JA, Sjoding MW, Konopka KE, Flott TL, VanEpps JS, Daniels RC, Ward KR, Stringer KA, Dickson RP. A novel swine model of the acute respiratory distress syndrome using clinically relevant injury exposures. Physiol Rep 2021; 9:e14871. [PMID: 33991456 PMCID: PMC8123544 DOI: 10.14814/phy2.14871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/17/2021] [Indexed: 12/18/2022] Open
Abstract
To date, existing animal models of the acute respiratory distress syndrome (ARDS) have failed to translate preclinical discoveries into effective pharmacotherapy or diagnostic biomarkers. To address this translational gap, we developed a high-fidelity swine model of ARDS utilizing clinically relevant lung injury exposures. Fourteen male swine were anesthetized, mechanically ventilated, and surgically instrumented for hemodynamic monitoring, blood, and tissue sampling. Animals were allocated to one of three groups: (1) Indirect lung injury only: animals were inoculated by direct injection of Escherichia coli into the kidney parenchyma, provoking systemic inflammation and distributive shock physiology; (2) Direct lung injury only: animals received volutrauma, hyperoxia, and bronchoscope-delivered gastric particles; (3) Combined indirect and direct lung injury: animals were administered both above-described indirect and direct lung injury exposures. Animals were monitored for up to 12 h, with serial collection of physiologic data, blood samples, and radiographic imaging. Lung tissue was acquired postmortem for pathological examination. In contrast to indirect lung injury only and direct lung injury only groups, animals in the combined indirect and direct lung injury group exhibited all of the physiological, radiographic, and histopathologic hallmarks of human ARDS: impaired gas exchange (mean PaO2 /FiO2 ratio 124.8 ± 63.8), diffuse bilateral opacities on chest radiographs, and extensive pathologic evidence of diffuse alveolar damage. Our novel porcine model of ARDS, built on clinically relevant lung injury exposures, faithfully recapitulates the physiologic, radiographic, and histopathologic features of human ARDS and fills a crucial gap in the translational study of human lung injury.
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Affiliation(s)
- Mohamad H. Tiba
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
| | - Brendan M. McCracken
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
| | - Danielle C. Leander
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
| | - Carmen I. Colmenero
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
| | - Jean A. Nemzek
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Unit of Laboratory Animal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Michael W. Sjoding
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMIUSA
- Department of Computational Medicine and BioinformaticsUniversity of MichiganAnn ArborMIUSA
| | - Kristine E. Konopka
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of PathologyUniversity of MichiganAnn ArborMIUSA
| | - Thomas L. Flott
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of Clinical PharmacyCollege of PharmacyUniversity of MichiganAnn ArborMIUSA
| | - J. Scott VanEpps
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of Biomedical EngineeringUniversity of MichiganAnn ArborMIUSA
- Biointerfaces InstituteUniversity of MichiganAnn ArborMIUSA
| | - Rodney C. Daniels
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of Biomedical EngineeringUniversity of MichiganAnn ArborMIUSA
- Department of PediatricsPediatric Critical Care MedicineUniversity of MichiganAnn ArborMIUSA
| | - Kevin R. Ward
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Department of Biomedical EngineeringUniversity of MichiganAnn ArborMIUSA
| | - Kathleen A. Stringer
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Department of Clinical PharmacyCollege of PharmacyUniversity of MichiganAnn ArborMIUSA
| | - Robert P. Dickson
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMIUSA
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Department of Microbiology & ImmunologyUniversity of MichiganAnn ArborMIUSA
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Kim EJ, Lee YH, Park JS, Lee J, Lee SY, Kim Y, Kwon YS, Jang JG, Shin KC, Kim KC, Choi EY. Clinical features and prognostic factors of critically ill patients with COVID-19 in Daegu, South Korea: A multi-center retrospective study. Medicine (Baltimore) 2021; 100:e24437. [PMID: 33607776 PMCID: PMC7899898 DOI: 10.1097/md.0000000000024437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 01/05/2021] [Indexed: 01/08/2023] Open
Abstract
To describe the clinical and demographic characteristics of critically ill patients with COVID-19 in Daegu, South Korea, and to explore the risk factors for in-hospital mortality in these patients.Retrospective cohort study of 110 critically ill patients with COVID-19 admitted to the ICU in Daegu, South Korea, between February 18 and April 5, 2020. The final date of follow-up was April 20, 2020.A total of 110 patient medical records were reviewed. The median age was 71 years (interquartile range [IQR] = 63-78 years). During the study period, 47 patients (42.7%) died in the hospital. The most common SARS-CoV-2 infection related complication was acute respiratory distress syndrome (ARDS) in 95 patients (86.4%). Of the 79 patients (71.8%) who received invasive mechanical ventilation, 46 (58.2%) received neuromuscular blockade injection, and 19 (24.1%) received ECMO treatment. All patients received antibiotic injection, 99 patients (90%) received hydroxychloroquine, 96 patients (87.3%) received lopinavir-ritonavir antiviral medication, and 14 patients (12.7%) received other antiviral agents, including darunavir-cobicistat and emtricitabine-tenofovir. In the multivariable logistic regression model, the odds ratio of in-hospital death was higher with APACHE II score (OR = 1.126; 95% CI = 1.014-1.252; P = .027).The in-hospital mortality rate of critically ill patients with COVID-19 was approximately 40%. Higher APACHE II score at admission was an independent risk factor for death in these patients.
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Affiliation(s)
- Eun Jin Kim
- Division of Pulmonary and Critical Care Medicine, Daegu Catholic university hospital
| | - Yong Hoon Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University
| | - Jae Seok Park
- Division of Pulmonology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University
| | - Shin Yup Lee
- Division of Pulmonary and Critical Care Medicine, Kyungpook National University Chilgok Hospital
| | - Yeonjae Kim
- Division of Pulmonary and Critical Care Medicine, Deagu Fatima Hospital
| | - Yong Shik Kwon
- Division of Pulmonology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine
| | - Jong Geol Jang
- Division of Pulmonary and Critical Care Medicine, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Kyeong-Cheol Shin
- Division of Pulmonary and Critical Care Medicine, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Kyung Chan Kim
- Division of Pulmonary and Critical Care Medicine, Daegu Catholic university hospital
| | - Eun Young Choi
- Division of Pulmonary and Critical Care Medicine, Yeungnam University Medical Center, Daegu, Republic of Korea
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Yu WK, McNeil JB, Wickersham NE, Shaver CM, Bastarache JA, Ware LB. Angiopoietin-2 outperforms other endothelial biomarkers associated with severe acute kidney injury in patients with severe sepsis and respiratory failure. Crit Care 2021; 25:48. [PMID: 33541396 PMCID: PMC7859898 DOI: 10.1186/s13054-021-03474-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/20/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Endothelial dysfunction and injury is a major pathophysiologic feature of sepsis. Sepsis is also the most frequent cause of acute kidney injury (AKI) in critically ill patients. Though most studies of AKI in sepsis have focused on tubular epithelial injury, the role of endothelial dysfunction and injury is less well studied. The goal of this study was first to investigate whether endothelial dysfunction and injury biomarkers were associated with severe AKI in sepsis patients. The second goal was to determine the best performing biomarker for severe AKI and whether this biomarker was associated with severe AKI across different etiologies of sepsis and clinical outcomes. METHODS We studied adults with severe sepsis and acute respiratory failure (ARF) enrolled in the prospective observational Validating Acute Lung Injury markers for Diagnosis (VALID) study. Plasma endothelial dysfunction and injury biomarkers, including angiopoietin-2, soluble vascular endothelial cadherin (sVE-cadherin), endocan and syndecan-1, were measured at study enrollment. Primary analysis focused on the association between endothelial biomarker levels with severe AKI (defined as Kidney Disease: Improving Global Outcomes [KDIGO] AKI stage 2 or 3), other organ dysfunctions (defined by Brussels organ failure scores), and comparison of pulmonary versus non-pulmonary sepsis. RESULTS Among 228 sepsis patients enrolled, 141 developed severe AKI. Plasma levels of angiopoietin-2, endocan, sVE-cadherin, and syndecan-1 were significantly higher in sepsis patients with severe AKI compared to those without severe AKI. Among four endothelial biomarkers, only angiopoietin-2 was independently associated with severe AKI (odds ratio 6.07 per log increase, 95% CI 2.34-15.78, p < 0.001). Plasma angiopoietin-2 levels by quartile were significantly higher in sepsis patients with hepatic, coagulation, and circulatory failure. Plasma angiopoietin-2 levels were also significantly higher in patients with non-pulmonary sepsis compared to subjects with pulmonary sepsis. CONCLUSION Among four biomarkers of endothelial dysfunction and injury, angiopoietin-2 had the most robust independent association with development of severe AKI in patients with severe sepsis and ARF. Plasma angiopoietin-2 levels were also associated with other organ dysfunctions, non-pulmonary sepsis, and death. These findings highlight the importance of early endothelial dysfunction and injury in the pathogenesis of sepsis-induced AKI.
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Affiliation(s)
- Wen-Kuang Yu
- grid.278247.c0000 0004 0604 5314Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Number 201, Section 2, Shipai Road, Beitou District, Taipei City, 11217 Taiwan, ROC ,grid.260770.40000 0001 0425 5914Institute of Physiology, National Yang-Ming University, Taipei, Taiwan ,grid.412807.80000 0004 1936 9916Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, T1218 MCN, 1161 21st, Avenue S, Nashville, TN 37232 USA
| | - J. Brennan McNeil
- grid.412807.80000 0004 1936 9916Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, T1218 MCN, 1161 21st, Avenue S, Nashville, TN 37232 USA
| | - Nancy E. Wickersham
- grid.412807.80000 0004 1936 9916Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, T1218 MCN, 1161 21st, Avenue S, Nashville, TN 37232 USA
| | - Ciara M. Shaver
- grid.412807.80000 0004 1936 9916Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, T1218 MCN, 1161 21st, Avenue S, Nashville, TN 37232 USA
| | - Julie A. Bastarache
- grid.412807.80000 0004 1936 9916Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, T1218 MCN, 1161 21st, Avenue S, Nashville, TN 37232 USA ,grid.152326.10000 0001 2264 7217Department of Cell and Developmental Biology, Vanderbilt University School of Medicine, Nashville, TN USA ,grid.152326.10000 0001 2264 7217Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, T1218 MCN, 1161 21st, Avenue S, Nashville, TN 37232 USA
| | - Lorraine B. Ware
- grid.412807.80000 0004 1936 9916Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, T1218 MCN, 1161 21st, Avenue S, Nashville, TN 37232 USA ,grid.152326.10000 0001 2264 7217Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, T1218 MCN, 1161 21st, Avenue S, Nashville, TN 37232 USA
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Song Y, Ye Y, Su SH, Stephens A, Cai T, Chung MT, Han M, Newstead MW, Yessayan L, Frame D, Humes D, Singer BH, Kurabayashi K. A digital protein microarray for COVID-19 cytokine storm monitoring. LAB ON A CHIP 2021; 21:331-343. [PMID: 33211045 PMCID: PMC7855944 DOI: 10.1039/d0lc00678e] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Despite widespread concern regarding cytokine storms leading to severe morbidity in COVID-19, rapid cytokine assays are not routinely available for monitoring critically ill patients. We report the clinical application of a digital protein microarray platform for rapid multiplex quantification of cytokines from critically ill COVID-19 patients admitted to the intensive care unit (ICU) at the University of Michigan Hospital. The platform comprises two low-cost modules: (i) a semi-automated fluidic dispensing/mixing module that can be operated inside a biosafety cabinet to minimize the exposure of the technician to the virus infection and (ii) a 12-12-15 inch compact fluorescence optical scanner for the potential near-bedside readout. The platform enabled daily cytokine analysis in clinical practice with high sensitivity (<0.4 pg mL-1), inter-assay repeatability (∼10% CV), and rapid operation providing feedback on the progress of therapy within 4 hours. This test allowed us to perform serial monitoring of two critically ill patients with respiratory failure and to support immunomodulatory therapy using the selective cytopheretic device (SCD). We also observed clear interleukin-6 (IL-6) elevations after receiving tocilizumab (IL-6 inhibitor) while significant cytokine profile variability exists across all critically ill COVID-19 patients and to discover a weak correlation between IL-6 to clinical biomarkers, such as ferritin and C-reactive protein (CRP). Our data revealed large subject-to-subject variability in patients' response to COVID-19, reaffirming the need for a personalized strategy guided by rapid cytokine assays.
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Affiliation(s)
- Yujing Song
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Yuxuan Ye
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Shiuan-Haur Su
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Andrew Stephens
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Tao Cai
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Meng-Ting Chung
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Meilan Han
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Michael W. Newstead
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Lenar Yessayan
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI, 48109, United States
| | - David Frame
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, United States
| | - David Humes
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Benjamin H. Singer
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, 48109, United States
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, 48109, United States
| | - Katsuo Kurabayashi
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, United States
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, 48109, United States
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, 48109, United States
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Abstract
PURPOSE OF REVIEW Given the growing body of critical care clinical research publications, core outcome sets (COSs) are important to help mitigate heterogeneity in outcomes assessed and measurement instruments used, and have potential to reduce research waste. This article provides an update on COS projects in critical care medicine, and related resources and tools for COS developers. RECENT FINDINGS We identified 28 unique COS projects, of which 15 have published results as of May 2020. COS topics relevant to critical care medicine include mechanical ventilation, cardiology, stroke, rehabilitation, and long-term outcomes (LTOs) after critical illness. There are four COS projects for coronavirus disease 2019 (COVID-19), with a 'meta-COS' summarizing common outcomes across these projects. To help facilitate COS development, there are existing resources, standards, guidelines, and tools available from the Core Outcome Measures in Effectiveness Trials Initiative (www.comet-initiative.org/) and the National Institutes of Health-funded Improve LTO project (www.improvelto.com/). SUMMARY Many COS projects have been completed in critical care, with more on-going COS projects, including foci from across the spectrum of acute critical care, COVID-19, critical care rehabilitation, and patient recovery and LTOs. Extensive resources are accessible to help facilitate rigorous COS development.
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