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Santa Cruz R, Matesa A, Gómez A, Nadur J, Pagano F, Prieto D, Bolaños O, Solis B, Yusta S, González-Velásquez E, Estenssoro E, Cavalcanti A. Mortality Due to Acute Respiratory Distress Syndrome in Latin America. Crit Care Med 2024; 52:1275-1284. [PMID: 38635486 DOI: 10.1097/ccm.0000000000006312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
OBJECTIVES Mortality due to acute respiratory distress syndrome (ARDS) is a major global health problem. Knowledge of epidemiological data on ARDS is crucial to design management, treatment strategies, and optimize resources. There is ample data regarding mortality of ARDS from high-income countries; in this review, we evaluated mortality due to ARDS in Latin America. DATA SOURCES We searched in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and Latin American and Caribbean Health Science Literature databases from 1967 to March 2023. STUDY SELECTION We searched prospective or retrospective observational studies and randomized controlled trials conducted in Latin American countries reporting ARDS mortality. DATA EXTRACTION Three pairs of independent reviewers checked all studies for eligibility based on their titles and abstracts. We performed meta-analysis of proportions using a random-effects model. We performed sensitivity analyses including studies with low risk of bias and with diagnosis using the Berlin definition. Subgroup analysis comparing different study designs, time of publication (up to 2000 and from 2001 to present), and studies in which the diagnosis of ARDS was made using Pa o2 /F io2 less than or equal to 200 and regional variations. Subsequently, we performed meta-regression analyses. Finally, we graded the certainty of the evidence (Grading of Recommendations Assessment, Development, and Evaluation). DATA SYNTHESIS Of 3315 articles identified, 32 were included (3627 patients). Mortality was 52% in the pooled group (low certainty of evidence). In the sensitivity analysis (according to the Berlin definition), mortality was 46% (moderate certainty of evidence). In the subgroup analysis mortality was 53% (randomized controlled trials), 51% (observational studies), 66% (studies published up to 2000), 50% (studies after 2000), 44% (studies with Pa o2 /F io2 ≤ 200), 56% (studies from Argentina/Brazil), and 40% (others countries). No variables were associated with mortality in the meta-regression. CONCLUSIONS ARDS mortality in Latin America remains high, as in other regions. These results should constitute the basis for action planning to improve the prognosis of patients with ARDS (PROSPERO [CRD42022354035]).
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Affiliation(s)
- Roberto Santa Cruz
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
- Instituto Universitario Ciencias de la Salud, Fundación Barceló, Argentina
| | - Amelia Matesa
- Clínica Basilea, Ciudad Autónoma de Buenos Aires, Argentina
| | - Antonella Gómez
- Hospital de Clínicas, Montevideo, Uruguay
- UDELAR, Universidad de la República, Montevideo, Uruguay
| | - Juan Nadur
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- Clínica CIAREC (Clínica de Internación Aguda en Rehabilitación y Cirugía), Buenos Aires, Argentina
| | - Fernando Pagano
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Prieto
- Hospital General Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Beatriz Solis
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
| | - Sara Yusta
- Universidad de Magallanes, Escuela de Medicina, Punta Arenas, Chile
| | | | - Elisa Estenssoro
- Dirección de Investigación, Escuela de Gobierno, Ministerio de Salud de la Provincia de Buenos Aires, Argentina
- Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina
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Qadir N, Bauer PR. Acute Respiratory Distress Syndrome and the Meaning of Hospital Mortality. Crit Care Med 2024; 52:1319-1321. [PMID: 39007577 DOI: 10.1097/ccm.0000000000006340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Affiliation(s)
- Nida Qadir
- Division of Pulmonary and Critical Care Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Ford VJ, Klein HG, Danner RL, Applefeld WN, Wang J, Cortes-Puch I, Eichacker PQ, Natanson C. Controls, comparator arms, and designs for critical care comparative effectiveness research: It's complicated. Clin Trials 2024; 21:124-135. [PMID: 37615179 PMCID: PMC10891304 DOI: 10.1177/17407745231195094] [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: 08/25/2023]
Abstract
BACKGROUND Comparative effectiveness research is meant to determine which commonly employed medical interventions are most beneficial, least harmful, and/or most costly in a real-world setting. While the objectives for comparative effectiveness research are clear, the field has failed to develop either a uniform definition of comparative effectiveness research or an appropriate set of recommendations to provide standards for the design of critical care comparative effectiveness research trials, spurring controversy in recent years. The insertion of non-representative control and/or comparator arm subjects into critical care comparative effectiveness research trials can threaten trial subjects' safety. Nonetheless, the broader scientific community does not always appreciate the importance of defining and maintaining critical care practices during a trial, especially when vulnerable, critically ill populations are studied. Consequently, critical care comparative effectiveness research trials sometimes lack properly constructed control or active comparator arms altogether and/or suffer from the inclusion of "unusual critical care" that may adversely affect groups enrolled in one or more arms. This oversight has led to critical care comparative effectiveness research trial designs that impair informed consent, confound interpretation of trial results, and increase the risk of harm for trial participants. METHODS/EXAMPLES We propose a novel approach to performing critical care comparative effectiveness research trials that mandates the documentation of critical care practices prior to trial initiation. We also classify the most common types of critical care comparative effectiveness research trials, as well as the most frequent errors in trial design. We present examples of these design flaws drawn from past and recently published trials as well as examples of trials that avoided those errors. Finally, we summarize strategies employed successfully in well-designed trials, in hopes of suggesting a comprehensive standard for the field. CONCLUSION Flawed critical care comparative effectiveness research trial designs can lead to unsound trial conclusions, compromise informed consent, and increase risks to research subjects, undermining the major goal of comparative effectiveness research: to inform current practice. Well-constructed control and comparator arms comprise indispensable elements of critical care comparative effectiveness research trials, key to improving the trials' safety and to generating trial results likely to improve patient outcomes in clinical practice.
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Affiliation(s)
- Verity J Ford
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortes-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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Hochberg CH, Card ME, Seth B, Hager DN, Eakin MN. Adaptation and Uncertainty: A Qualitative Examination of Provider Experiences With Prone Positioning for Intubated Patients With COVID-19 ARDS. CHEST CRITICAL CARE 2023; 1:100008. [PMID: 37810258 PMCID: PMC10560392 DOI: 10.1016/j.chstcc.2023.100008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND Prone positioning was widely adopted for use in patients with ARDS from COVID-19. However, proning was also delivered in ways that differed from historical evidence and practice. In implementation research, these changes are referred to as adaptations, and they occur constantly as evidence-based interventions are used in real-world practice. Adaptations can alter the delivered intervention, impacting patient and implementation outcomes. RESEARCH QUESTION How have clinicians adapted prone positioning to COVID-19 ARDS, and what uncertainties remain regarding optimal proning use? STUDY DESIGN AND METHODS We conducted a qualitative study using semi-structured interviews with ICU clinicians from two hospitals in Baltimore, MD, from February to July 2021. We interviewed physicians (MDs), registered nurses (RNs), respiratory therapists (RTs), advanced practice providers (APPs), and physical therapists (PTs) involved with proning mechanically ventilated patients with COVID-19 ARDS. We used thematic analysis of interviews to classify proning adaptations and clinician uncertainties about best practice for prone positioning. RESULTS Forty ICU clinicians (12 MDs, 4 APPs, 12 RNs, 7 RTs, and 5 PTs) were interviewed. Clinicians described several adaptations to the practice of prone positioning, including earlier proning initiation, extended duration of proning sessions, and less use of concomitant neuromuscular blockade. Clinicians expressed uncertainty regarding the optimal timing of initiation and duration of prone positioning. This uncertainty was viewed as a driver of practice variation. Although prescribers intended to use less deep sedation and paralysis in proned patients compared with historical evidence and practice, this raised concerns regarding patient comfort and safety amongst RNs and RTs. INTERPRETATION Prone positioning in patients with COVID-19 ARDS has been adapted from historically described practice. Understanding the impact of these adaptations on patient and implementation outcomes and addressing clinician uncertainties are priority areas for future research to optimize the use of prone positioning.
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Affiliation(s)
- Chad H Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Mary E Card
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
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Grissom CK, Lanspa MJ, Groat D, Jacobs JR, Carpenter L, Kuttler KG, Leither L, Peltan ID, Brown SM, Srivastava R. Implementation of Lung-Protective Ventilation in Patients With Acute Respiratory Failure. Crit Care Med 2023; 51:797-807. [PMID: 36988337 DOI: 10.1097/ccm.0000000000005840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
OBJECTIVES We implemented a computerized protocol for low tidal volume ventilation (LTVV) to improve management and outcomes of mechanically ventilated patients with, and without, the acute respiratory distress syndrome (ARDS). DESIGN Pragmatic, nonrandomized stepped wedge type II hybrid implementation/effectiveness trial. SETTING Twelve hospitals in an integrated healthcare system over a 2-year period. PATIENTS Patients greater than or equal to 18 years old who had initiation of mechanical ventilation in the emergency department or ICU. We excluded patients who died or transitioned to comfort care on the day of admission to the ICU. We defined a subgroup of patients with ARDS for analysis. INTERVENTIONS Implementation of ventilator protocols for LTVV in the ICU. MEASUREMENTS AND MAIN RESULTS Our primary clinical outcome was ventilator-free days (VFDs) to day 28. Our primary process outcome was median initial set tidal volume. We included 8,692 mechanically ventilated patients, 3,282 (38%) of whom had ARDS. After implementation, set tidal volume reported as mL/kg predicted body weight decreased from median 6.1 mL/kg (interquartile range [IQR], 6.0-6.8 mL/kg) to 6.0 mL/kg (IQR, 6.0-6.6 mL/kg) ( p = 0.009). The percent of patients receiving LTVV (tidal volume ≤ 6.5 mL/kg) increased from 69.8% ( n = 1,721) to 72.5% ( n = 1,846) ( p = 0.036) after implementation. The percent of patients receiving greater than 8 mL/kg initial set tidal volume was reduced from 9.0% ( n = 222) to 6.7% ( n = 174) ( p = 0.005) after implementation. Among patients with ARDS, day 1 positive end-expiratory pressure increased from 6.7 to 8.0 cm H 2 O ( p < 0.001). We observed no difference in VFD (adjusted odds ratio, 1.06; 95% CI, 0.91-1.24; p = 0.44), or in secondary outcomes of length of stay or mortality, either within the main cohort or the subgroup of patients with ARDS. CONCLUSIONS We observed improved adherence to optimal ventilator management with implementation of a computerized protocol and reduction in the number of patients receiving tidal volumes greater than 8 mL/kg. We did not observe improvement in clinical outcomes.
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Affiliation(s)
- Colin K Grissom
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Michael J Lanspa
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Danielle Groat
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Jason R Jacobs
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Lori Carpenter
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Kathryn G Kuttler
- Digital Technology Services, Intermountain Healthcare, Salt Lake City, UT
| | - Lindsay Leither
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, UT
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT
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Capellier G, Barrot L, Winizewski H. Oxygenation target in acute respiratory distress syndrome. JOURNAL OF INTENSIVE MEDICINE 2023:S2667-100X(23)00022-1. [PMID: 37362867 PMCID: PMC10181914 DOI: 10.1016/j.jointm.2023.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 06/28/2023]
Abstract
Determining oxygenation targets in acute respiratory distress syndrome (ARDS) remains a challenge. Although oxygenation targets have been used since ARDS was first described, they have not been investigated in detail. However, recent retrospective and prospective trials have evaluated the optimal oxygenation threshold in patients admitted to the general intensive care unit. In view of the lack of prospective data, clinicians continue to rely on data from the few available trials to identify the optimal oxygenation strategy. Assessment of the cost-benefit ratio of the fraction of inspired oxygen (FiO2) to the partial pressure of oxygen in the arterial blood (PaO2) is an additional challenge. A high FiO2 has been found to be responsible for respiratory failure and deaths in numerous animal models. Low and high PaO2 values have also been demonstrated to be potential risk factors in experimental and clinical situations. The findings from this literature review suggest that PaO2 values ranging between 80 mmHg and 90 mmHg are acceptable in patients with ARDS. The costs of rescue maneuvers needed to reach these targets have been discussed. Several recent papers have highlighted the risk of disagreement between arterial oxygen saturation (SaO2) and peripheral oxygen saturation (SpO2) values. In order to avoid discrepancies and hidden hypoxemia, SpO2 readings need to be compared with those of SaO2. Higher SpO2 values may be needed to achieve the recommended PaO2 and SaO2 values.
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Affiliation(s)
- Gilles Capellier
- Réanimation Médicale, CHU Jean Minjoz, Besançon 25000, France
- Department of Health, Monash University, Melbourne 3800, Australia
- Equipe d'accueil EA 3920, Université de Franche Comte, Besançon 25000, France
| | - Loic Barrot
- Réanimation Médicale, CHU Jean Minjoz, Besançon 25000, France
- Département d'Anesthésie-Réanimation, CHU Jan Minjoz, Besançon 25000, France
| | - Hadrien Winizewski
- Réanimation Médicale, CHU Jean Minjoz, Besançon 25000, France
- Equipe d'accueil EA 3920, Université de Franche Comte, Besançon 25000, France
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Abstract
Aerosolized prostacyclins are frequently used in patients with severe acute respiratory distress syndrome and refractory hypoxia. Previous studies have shown improvement in oxygenation with use of pulmonary vasodilators such as iloprost and epoprostenol; however, there is no head-to-head comparison between these agents. OBJECTIVES To compare the effects of inhaled epoprostenol and inhaled iloprost in critically ill patients with refractory hypoxia. DESIGN SETTING AND PARTICIPANTS We performed a retrospective cohort analysis of patients admitted to the ICUs at the University of Oklahoma Health Sciences Center between 2015 and 2018. Adult patients who received aerosolized epoprostenol or iloprost for more than 4 hours were included in the analysis. MAIN OUTCOMES AND MEASURES The primary endpoint measured was to compare the change in Pao2/Fio2 ratio between patients treated with iloprost compared with epoprostenol. Secondary outcomes measured were 90-day in-hospital mortality and improvement in vasopressor requirements. RESULTS A total of 126 patients were included in the study, 95 of whom received iloprost (75%) and 31 patients (25%) received epoprostenol. There were significant improvements in Pao2/Fio2 ratio in both the iloprost and epoprostenol group. Patients in the epoprostenol group appeared to have a higher 90-day mortality compared with the iloprost group. However, our study was not powered to detect a mortality difference and this finding likely represents a sicker population in the epoprostenol group and prescription bias. The use of iloprost was associated with higher vasopressor requirements in the first 12 hours of administration, an association was not observed in the epoprostenol group. CONCLUSIONS AND RELEVANCE In this retrospective cohort analysis, use of both pulmonary vasodilators was associated with similar improvement in gas exchange. The mortality difference observed likely represents difference in severity of illness. Further studies are needed to corroborate these findings.
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Savoie-White FH, Tremblay L, Menier CA, Duval C, Bergeron F, Tadrous M, Tougas J, Guertin JR, Ugalde PA. The use of early neuromuscular blockage in acute respiratory distress syndrome: A systematic review and meta-analyses of randomized clinical trials. Heart Lung 2023; 57:186-197. [PMID: 36242824 DOI: 10.1016/j.hrtlng.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/12/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute Respiratory Distress Syndrome (ARDS) as defined by the Berlin definition has an approximate mortality rate of 40% and no curative treatment. Mutliple therapies have been studied to reduce mortality but only neuromuscular blocking agents show potential benefits on mortality and other complications of ARDS. OBJECTIVE This review aimed to investigate the efficacy of neuromuscular blockers in ARDS METHODS: Medline, Embase, Cochrane Central and Web of Science were queried on October 1st, 2021. Randomized clinical trials comparing neuromuscular blockers to any comparator in treating ARDS were included. Primary outcome was mortality. Secondary outcomes were ventilator-free days, intensive care (ICU) length of stay (LOS) and complications. Results between sedation levels were examined with a Bayesian Network for Meta-analysis method. RESULTS We included 6 trials compiling a total of 1557 patients. Neuromuscular blockers compared to any comparator in treating ARDS showed a reduction in mortality (RR 0.79 [95% CI, 0.62 to 0.99]). No difference in ventilator-free days (MD 0.68 [95% CI, -0.50 to 1.85]) or ICU LOS (MD 0.77 [95% CI, -2.99 to 4.54]) were found. A Bayesian Network Meta-analysis yielded no difference in mortality when using light sedation compared to heavy sedation in ARDS. (OR 0.58 [95% CrI, 0.07 to 4.46].) CONCLUSION: Neuromuscular blockers safely reduce mortality. Light sedation potentially has a similar impact on mortality as heavy sedation that carries some burden. A non-inferiority trial comparing both sedation levels may be warranted considering the added value of light sedation.
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Affiliation(s)
- Félix H Savoie-White
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada; Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Québec, Canada; Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada.
| | - Laurence Tremblay
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Charles Antoine Menier
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Cécile Duval
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Québec, Canada
| | | | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jade Tougas
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Jason R Guertin
- Department of Pulmonology and Thoracic Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada; Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Paula A Ugalde
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard University, Cambridge, Boston, United States
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Hochberg CH, Card ME, Seth B, Kerlin MP, Hager DN, Eakin MN. Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic: A Qualitative Study. Ann Am Thorac Soc 2023; 20:83-93. [PMID: 35947776 PMCID: PMC9819268 DOI: 10.1513/annalsats.202204-349oc] [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: 04/21/2022] [Accepted: 08/10/2022] [Indexed: 02/05/2023] Open
Abstract
Rationale: The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients with coronavirus disease (COVID-19) ARDS, proning has increased. Understanding the factors influencing this change is important for further expanding and sustaining the use of prone positioning in appropriate clinical settings. Objectives: To characterize factors influencing the implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS. Methods: We conducted a qualitative study using semistructured interviews with 40 intensive care unit (ICU) team members (physicians, nurses, advanced practice providers, respiratory therapists, and physical therapists) working at two academic hospitals. We used the Consolidated Framework for Implementation Research, a widely used implementation science framework outlining important features of implementation, to structure the interview guide and thematic analysis of interviews. Results: ICU clinicians reported that during the COVID-19 pandemic, proning was viewed as standard early therapy for COVID-19 ARDS rather than salvage therapy for refractory hypoxemia. By caring for large volumes of proned patients, clinicians gained increased comfort with proning and now view proning as a low-risk, high-benefit intervention. Within ICUs, adequate numbers of trained staff members, increased team agreement around proning, and the availability of specific equipment (e.g., to limit pressure injuries) facilitated greater proning use. Hospital-level supports included proning teams, centralized educational resources specific to the management of COVID-19 (including a recommendation for prone positioning), and an electronic medical record proning order. Important implementation processes included informal dissemination of best practices through on-the-job learning and team interactions during routine bedside care. Conclusions: The implementation of prone positioning for COVID-19 ARDS took place in the context of evolving clinician viewpoints and ICU team cultures. Proning was facilitated by hospital support and buy-in and leadership from bedside clinicians. The successful implementation of prone positioning during the COVID-19 pandemic may serve as a model for the implementation of other evidence-based therapies in critical care.
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Affiliation(s)
- Chad H. Hochberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Mary E. Card
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Meeta P. Kerlin
- Pulmonary, Allergy and Critical Care Division, Department of Medicine, Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David N. Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
| | - Michelle N. Eakin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland; and
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Train SE, Burns KEA, Erstad BL, Massaro A, Wu TT, Vassaur J, Selvan K, Kress JP, Devlin JW. Physicians' attitudes and perceptions of neuromuscular blocker infusions in ARDS. J Crit Care 2022; 72:154165. [PMID: 36209698 DOI: 10.1016/j.jcrc.2022.154165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The perceptions and practices of ICU physicians regarding initiating neuromuscular blocker infusions (NMBI) in acute respiratory distress syndrome (ARDS) may not be evidence-based amidst the surge of severe ARDS during the SARS-CoV-2 pandemic and new practice guidelines. We identified ICU physicians' perspectives and practices regarding NMBI use in adults with moderate-severe ARDS. MATERIALS AND METHODS After extensive development and testing, an electronic survey was distributed to 342 ICU physicians from three geographically-diverse U.S. health systems(n = 12 hospitals). RESULTS The 173/342 (50.5%) respondents (75% medical) somewhat/strongly agreed a NMBI should be reserved until: after a trial of deep sedation (142, 82%) or proning (59, 34%) and be dose-titrated based on train-of-four monitoring (107, 62%). Of 14 potential NMBI risks, 2 were frequently reported to be of high/very high concern: prolonged muscle weakness with steroid use (135, 79%) and paralysis awareness due to inadequate sedation (114, 67%). Absence of dyssychrony (93, 56%) and use ≥48 h (87, 53%) were preferred NMBI stopping criteria. COVID-19 + ARDS patients were twice as likely to receive a NMBI (56 ± 37 vs. 28 ± 19%, p < 0.01). CONCLUSIONS Most intensivists agreed NMBI in ARDS should be reserved until after a deep sedation trial. Stopping criteria remain poorly defined. Unique considerations exist regarding the role of paralysis in COVID-19+ ARDS.
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Affiliation(s)
- Sarah E Train
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Karen E A Burns
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Brian L Erstad
- College of Pharmacy, University of Arizona, Tucson, AZ, United States of America
| | - Anthony Massaro
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Ting Ting Wu
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Bouve College of Health Sciences, Northeastern University, Boston, MA, United States of America
| | - John Vassaur
- Division of Pulmonary and Critical Care Medicine, University of Arizona Medical Center, Tucson, AZ, United States of America
| | - Kavitha Selvan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Chicago Medical Center, Chicago, IL, United States of America
| | - John P Kress
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Chicago Medical Center, Chicago, IL, United States of America
| | - John W Devlin
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Bouve College of Health Sciences, Northeastern University, Boston, MA, United States of America.
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Law AC, Bosch NA, Walkey AJ. Procedure Codes for Intubated Prone Positioning: A Turn for the Better. Ann Am Thorac Soc 2022; 19:1634-1635. [PMID: 35608404 PMCID: PMC9528737 DOI: 10.1513/annalsats.202204-306vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/23/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Anica C Law
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Nicholas A Bosch
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Allan J Walkey
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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12
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Abstract
Acute respiratory distress syndrome (ARDS) occurs in up to 10% of patients with respiratory failure admitted through the emergency department. Use of noninvasive respiratory support has proliferated in recent years; clinicians must understand the relative merits and risks of these technologies and know how to recognize signs of failure. The cornerstone of ARDS care of the mechanically ventilated patient is low-tidal volume ventilation based on ideal body weight. Adjunctive therapies, such as prone positioning and neuromuscular blockade, may have a role in the emergency department management of ARDS depending on patient and department characteristics.
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Affiliation(s)
- Alin Gragossian
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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13
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Applefeld WN, Wang J, Cortés-Puch I, Klein HG, Eichacker PQ, Cooper D, Danner RL, Natanson C. Modeling current practices in critical care comparative effectiveness research. CRIT CARE RESUSC 2022; 24:150-162. [PMID: 38045594 PMCID: PMC10692606 DOI: 10.51893/2022.2.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To determine whether contemporaneous practices are adequately represented in recent critical care comparative effectiveness research studies. Design: All critical care comparative effectiveness research trials published in the New England Journal of Medicine from April 2019 to March 2020 were identified. To examine studies published in other high impact medical journals during the same period, such trials were subsequently also identified in the Journal of the American Medical Association and The Lancet. All cited sources were reviewed, and the medical literature was searched to find studies describing contemporary practices. Then, the designated control group or the comparable therapies studied were examined to determine if they represented contemporaneous critical care practices as described in the medical literature. Results: Twenty-five of 332 randomised clinical trials published in these three journals during this 1-year period described critical care comparative effectiveness research that met our inclusion criteria. Seventeen characterised current practices before enrolment (using surveys, observational studies and guidelines) and then incorporated current practices into one or more study arm. In the other eight, usual care arms appeared insufficient. Four of these trials randomly assigned patients to one of two fixed approaches at either end of a range of usually titrated care. However, due to randomisation, different subgroups within each arm received care that was inappropriate for their specific clinical conditions. In the other four of these trials, common practices influencing treatment choice were not reflected in the trial design, despite a prior effort to characterise usual care. Conclusion: One-third of critical care comparative effectiveness research trials published in widely read medical journals during a recent year did not include a designated control arm or comparable therapies representative of contemporary practices. Failure to incorporate contemporary practices into critical care comparative effectiveness trials appears to be a widespread design weakness.
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Affiliation(s)
- Willard N. Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortés-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Harvey G. Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Peter Q. Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Diane Cooper
- National Institutes of Health Library, Office of Research Services, National Institutes of Health, Bethesda, MD, USA
| | - Robert L. Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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14
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Núñez-Seisdedos MN, Lázaro-Navas I, López-González L, López-Aguilera L. Intensive Care Unit- Acquired Weakness and Hospital Functional Mobility Outcomes Following Invasive Mechanical Ventilation in Patients with COVID-19: A Single-Centre Prospective Cohort Study. J Intensive Care Med 2022; 37:1005-1014. [PMID: 35578542 PMCID: PMC9117955 DOI: 10.1177/08850666221100498] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Acute physical function outcomes in ICU survivors of COVID-19 pneumonia has received little attention. Critically ill patients with COVID-19 infection who require invasive mechanical ventilation may undergo greater exposure to some risk factors for ICU-acquired weakness (ICUAW). Purpose: To determine incidence and factors associated with ICUAW at ICU discharge and gait dependence at hospital discharge in mechanically ventilated patients with COVID-19 pneumonia. Methods: Single-centre, prospective cohort study conducted at a tertiary hospital in Madrid, Spain. We evaluated ICUAW with the Medical Research Council Summary Score (MRC-SS). Gait dependence was assessed with the Functional Status Score for the ICU (FSS-ICU) walking subscale. Results: During the pandemic second wave, between 27 July and 15 December, 2020, 70 patients were enrolled. ICUAW incidence was 65.7% and 31.4% at ICU discharge and hospital discharge, respectively. Gait dependence at hospital discharge was observed in 66 (54.3%) patients, including 9 (37.5%) without weakness at ICU discharge. In univariate analysis, ICUAW was associated with the use of neuromuscular blockers (crude odds ratio [OR] 9.059; p = 0.01) and duration of mechanical ventilation (OR 1.201; p = 0.001), but not with the duration of neuromuscular blockade (OR 1.145, p = 0.052). There was no difference in corticosteroid use between patients with and without weakness. Associations with gait dependence were lower MRC-SS at ICU discharge (OR 0.943; p = 0.015), older age (OR 1.126; p = 0.001), greater Charlson Comorbidity Index (OR 1.606; p = 0.011), longer duration of mechanical ventilation (OR 1.128; p = 0.001) and longer duration of neuromuscular blockade (OR 1.150; p = 0.029). Conclusions: In critically ill COVID-19 patients, the incidence of ICUAW and acute gait dependence were high. Our study identifies factors influencing both outcomes. Future studies should investigate optimal COVID-19 ARDS management and impact of dyspnea on acute functional outcomes of COVID-19 ICU survivors.
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Affiliation(s)
| | - Irene Lázaro-Navas
- Physiotherapy Department, 16507Ramón y Cajal University Hospital, Madrid, Spain
| | - Luís López-González
- Physiotherapy Department, 16507Ramón y Cajal University Hospital, Madrid, Spain
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15
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Miller AG, Tan HL, Smith BJ, Rotta AT, Lee JH. The Physiological Basis of High-Frequency Oscillatory Ventilation and Current Evidence in Adults and Children: A Narrative Review. Front Physiol 2022; 13:813478. [PMID: 35557962 PMCID: PMC9087180 DOI: 10.3389/fphys.2022.813478] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/08/2022] [Indexed: 12/12/2022] Open
Abstract
High-frequency oscillatory ventilation (HFOV) is a type of invasive mechanical ventilation that employs supra-physiologic respiratory rates and low tidal volumes (VT) that approximate the anatomic deadspace. During HFOV, mean airway pressure is set and gas is then displaced towards and away from the patient through a piston. Carbon dioxide (CO2) is cleared based on the power (amplitude) setting and frequency, with lower frequencies resulting in higher VT and CO2 clearance. Airway pressure amplitude is significantly attenuated throughout the respiratory system and mechanical strain and stress on the alveoli are theoretically minimized. HFOV has been purported as a form of lung protective ventilation that minimizes volutrauma, atelectrauma, and biotrauma. Following two large randomized controlled trials showing no benefit and harm, respectively, HFOV has largely been abandoned in adults with ARDS. A multi-center clinical trial in children is ongoing. This article aims to review the physiologic rationale for the use of HFOV in patients with acute respiratory failure, summarize relevant bench and animal models, and discuss the potential use of HFOV as a primary and rescue mode in adults and children with severe respiratory failure.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Respiratory Care Services, Durham, NC, United States
| | - Herng Lee Tan
- KK Women's and Children's Hospital, Children's Intensive Care Unit, Singapore, Singapore
| | - Brian J Smith
- University of California, Davis, Respiratory Care Services, Sacramento, CA, United States
| | - Alexandre T Rotta
- Duke University Medical Center, Division of Pediatric Critical Care Medicine, Durham, NC, United States
| | - Jan Hau Lee
- KK Women's and Children's Hospital, Children's Intensive Care Unit, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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16
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Hochberg CH, Psoter KJ, Sahetya SK, Nolley EP, Hossen S, Checkley W, Kerlin MP, Eakin MN, Hager DN. Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome. Crit Care Explor 2022; 4:e0695. [PMID: 35783548 PMCID: PMC9243245 DOI: 10.1097/cce.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Use of prone positioning in patients with acute respiratory distress syndrome (ARDS) from COVID-19 may be greater than in patients treated for ARDS before the pandemic. However, the magnitude of this increase, sources of practice variation, and the extent to which use adheres to guidelines is unknown.
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17
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Knighton AJ, Kuttler KG, Ranade-Kharkar P, Allen L, Throne T, Jacobs JR, Carpenter L, Winberg C, Johnson K, Shrestha N, Ferraro JP, Wolfe D, Peltan ID, Srivastava R, Grissom CK. An alert tool to promote lung protective ventilation for possible acute respiratory distress syndrome. JAMIA Open 2022; 5:ooac050. [PMID: 35815095 PMCID: PMC9263532 DOI: 10.1093/jamiaopen/ooac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/26/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Computer-aided decision tools may speed recognition of acute respiratory distress syndrome (ARDS) and promote consistent, timely treatment using lung-protective ventilation (LPV). This study evaluated implementation and service (process) outcomes with deployment and use of a clinical decision support (CDS) synchronous alert tool associated with existing computerized ventilator protocols and targeted patients with possible ARDS not receiving LPV. Materials and Methods We performed an explanatory mixed methods study from December 2019 to November 2020 to evaluate CDS alert implementation outcomes across 13 intensive care units (ICU) in an integrated healthcare system with >4000 mechanically ventilated patients annually. We utilized quantitative methods to measure service outcomes including CDS alert tool utilization, accuracy, and implementation effectiveness. Attitudes regarding the appropriateness and acceptability of the CDS tool were assessed via an electronic field survey of physicians and advanced practice providers. Results Thirty-eight percent of study encounters had at least one episode of LPV nonadherence. Addition of LPV treatment detection logic prevented an estimated 1812 alert messages (41%) over use of disease detection logic alone. Forty-eight percent of alert recommendations were implemented within 2 h. Alert accuracy was estimated at 63% when compared to gold standard ARDS adjudication, with sensitivity of 85% and positive predictive value of 62%. Fifty-seven percent of survey respondents observed one or more benefits associated with the alert. Conclusion Introduction of a CDS alert tool based upon ARDS risk factors and integrated with computerized ventilator protocol instructions increased visibility to gaps in LPV use and promoted increased adherence to LPV.
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Affiliation(s)
- Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
| | - Kathryn G Kuttler
- Digital Technology Services, Intermountain Healthcare , Salt Lake City, Utah, USA
| | | | - Lauren Allen
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
| | - Taylor Throne
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
| | - Jason R Jacobs
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
| | - Lori Carpenter
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
| | - Carrie Winberg
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
| | - Kyle Johnson
- Digital Technology Services, Intermountain Healthcare , Salt Lake City, Utah, USA
| | - Neer Shrestha
- Digital Technology Services, Intermountain Healthcare , Salt Lake City, Utah, USA
| | - Jeffrey P Ferraro
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine , Salt Lake City, Utah, USA
| | - Doug Wolfe
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
| | - Ithan D Peltan
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine , Salt Lake City, Utah, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Healthcare , Murray, Utah, USA
- Department of Pediatrics, University of Utah School of Medicine , Salt Lake City, Utah, USA
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine Department of Medicine, Intermountain Medical Center , Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine , Salt Lake City, Utah, USA
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18
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Terzi N, Guérin C. Optimizing Mechanical Ventilation in Refractory ARDS. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8740657 DOI: 10.1016/b978-0-12-801238-3.11480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical ventilation in patients with refractory acute respiratory distress syndrome (ARDS) must provide lung protection. This is achieved by limiting tidal volume (VT) and plateau pressure (Pplat). With the current evidence available VT should be initially set around 6 mL per kg predicted body weight and PPlat maintained below 30 cmH2O and monitored. Positive end-expiratory pressure (PEEP), which also contributes to lung protection, should be set > 12 cmH2O, provided oxygenation gets improved, with same Pplat target. Recruitment maneuvers should be used with caution avoiding higher PEEP. Neuromuscular blockade should be started and prone position performed for sessions longer than 16 h. High frequency oscillation ventilation should be used in expert centers only if previous management failed to improve oxygenation.
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19
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The Use of Inhaled Epoprostenol for Acute Respiratory Distress Syndrome Secondary due to COVID-19: A Case Series. J Crit Care Med (Targu Mures) 2021; 8:33-40. [PMID: 35274053 PMCID: PMC8852286 DOI: 10.2478/jccm-2021-0037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 09/27/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Inhaled epoprostenol (iEpo) is a pulmonary vasodilator used to treat refractory respiratory failure, including that caused by Coronavirus 2019 (COVID-19) pneumonia. Aim of Study To describe the experience at three teaching hospitals using iEpo for severe respiratory failure due to COVID-19 and evaluate its efficacy in improving oxygenation. Methods Fifteen patients were included who received iEpo, had confirmed COVID-19 and had an arterial blood gas measurement in the 12 hours before and 24 hours after iEpo initiation. Results Eleven patients received prone ventilation before iEpo (73.3%), and six (40%) were paralyzed. The partial pressure of arterial oxygen to fraction of inspired oxygen (P/F ratio) improved from 95.7 mmHg to 118.9 mmHg (p=0.279) following iEpo initiation. In the nine patients with severe ARDS, the mean P/F ratio improved from 66.1 mmHg to 95.7 mmHg (p=0.317). Ultimately, four patients (26.7%) were extubated after an average of 9.9 days post-initiation. Conclusions The findings demonstrated a trend towards improvement in oxygenation in critically ill COVID-19 patients. Although limited by the small sample size, the results of this case series portend further investigation into the role of iEpo for severe respiratory failure associated with COVID-19.
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20
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The Severe ARDS Generating Evidence (SAGE) Study: A Call for Action in the Daily Clinical Practice. Chest 2021; 160:1167-1168. [PMID: 34625163 PMCID: PMC8490917 DOI: 10.1016/j.chest.2021.07.2158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 11/21/2022] Open
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21
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Qadir N, Bartz RR, Cooter ML, Hough CL, Lanspa MJ, Banner-Goodspeed VM, Chen JT, Giovanni S, Gomaa D, Sjoding MW, Hajizadeh N, Komisarow J, Duggal A, Khanna AK, Kashyap R, Khan A, Chang SY, Tonna JE, Anderson HL, Liebler JM, Mosier JM, Morris PE, Genthon A, Louh IK, Tidswell M, Stephens RS, Esper AM, Dries DJ, Martinez A, Schreyer KE, Bender W, Tiwari A, Guru PK, Hanna S, Gong MN, Park PK. Variation in Early Management Practices in Moderate-to-Severe ARDS in the United States: The Severe ARDS: Generating Evidence Study. Chest 2021; 160:1304-1315. [PMID: 34089739 PMCID: PMC8176896 DOI: 10.1016/j.chest.2021.05.047] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 05/03/2021] [Accepted: 05/10/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although specific interventions previously demonstrated benefit in patients with ARDS, use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. RESEARCH QUESTION What is the impact of treatment variability on mortality in patients with moderate to severe ARDS in the United States? STUDY DESIGN AND METHODS We conducted a multicenter, observational cohort study of mechanically ventilated adults with ARDS and Pao2 to Fio2 ratio of ≤ 150 with positive end-expiratory pressure of ≥ 5 cm H2O, who were admitted to 29 US centers between October 1, 2016, and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality also were assessed. RESULTS A total of 2,466 patients were enrolled. Median baseline Pao2 to Fio2 ratio was 105 (interquartile range, 78.0-129.0). In-hospital 28-day mortality was 40.7%. Initial adherence to lung protective ventilation (LPV; tidal volume, ≤ 6.5 mL/kg predicted body weight; plateau pressure, or when unavailable, peak inspiratory pressure, ≤ 30 mm H2O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), methods used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7%-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early LPV was correlated with SMR. INTERPRETATION Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03021824; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Nida Qadir
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Raquel R Bartz
- Division of Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Mary L Cooter
- Division of Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Michael J Lanspa
- Division of Pulmonary Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT; Intermountain Medical Center, Murray, UT
| | - Valerie M Banner-Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jen-Ting Chen
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - Shewit Giovanni
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Dina Gomaa
- Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH
| | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Negin Hajizadeh
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Jordan Komisarow
- Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA; Department of Neurosurgery, Duke University Medical Center, Durham, NC
| | - Abhijit Duggal
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH
| | - Ashish K Khanna
- Section of Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC; Outcomes Research Consortium, Cleveland, OH
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Akram Khan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Steven Y Chang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Joseph E Tonna
- Divisions of Cardiothoracic Surgery and Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Janice M Liebler
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Peter E Morris
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Alissa Genthon
- Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
| | - Irene K Louh
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; New York-Presbyterian Hospital
| | - Mark Tidswell
- Division of Pulmonary and Critical Care Medicine Baystate Medical Center and University of Massachusetts Medical School, Springfield, MA
| | - R Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annette M Esper
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - David J Dries
- Department of Surgery, Regions Medical Center, St. Paul, MN
| | | | - Kraftin E Schreyer
- Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA
| | - William Bender
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Anupama Tiwari
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Albany Medical College, Albany, NY
| | - Pramod K Guru
- Division of Critical Care Medicine, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Sinan Hanna
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Michelle N Gong
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY
| | - Pauline K Park
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
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22
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Roberts A. Understanding the principles of non-invasive positive pressure ventilation. Nurs Stand 2021; 36:61-66. [PMID: 34219428 DOI: 10.7748/ns.2021.e11750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 11/09/2022]
Abstract
Non-invasive positive pressure ventilation (NPPV) provides respiratory support to patients without the need for invasive intubation. Although it has been used for several years in critical care, NPPV has come to prominence as a management option for certain patients with respiratory complications of coronavirus disease 2019 (COVID-19). This has led to increased care provision by nurses with little or no experience and expertise in critical care and NPPV. This article provides an overview of the principles of NPPV and its use in type 1 and type 2 respiratory failure. It explains the pathophysiology of several conditions that often lead to respiratory failure and how NPPV can mitigate respiratory failure and improve gas exchange. An individualised assessment of the patient's suitability for NPPV and an evaluation of the effectiveness of the therapy are crucial to ensure its safe and effective use. Nurses also have an important role in providing explanations and support to patients.
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Affiliation(s)
- Alexandra Roberts
- Faculty of Health Studies, School of Nursing and Healthcare Leadership, University of Bradford, Bradford, England
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23
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Jha A, Vasques F, Sanderson B, Daly K, Glover G, Ioannou N, Wyncoll D, Sherren P, Langrish C, Meadows C, Retter A, Paul R, Barrett NA, Camporota L. A survey on the practices and capabilities in the management of respiratory failure in South East England. J Intensive Care Soc 2021; 22:175-181. [PMID: 34025757 DOI: 10.1177/1751143720928895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction The variability of acute respiratory distress syndrome management may affect the referral practice to severe respiratory failure centres. We described the management of acute respiratory distress syndrome in our catchment area. Methods An electronic survey was administered to 42 intensive care units in South-East England. Results Response rate was 71.4%. High-flow nasal oxygen and non-invasive ventilation were used 'often' in moderate-acute respiratory distress syndrome by 46.7% and 60%. During invasive ventilation, 90% preferred pressure control, targeting tidal volumes of 6-8 ml/kg (53.3%) or 4-6 ml/kg (46.7%). Positive end-expiratory pressure was selected by positive end-expiratory pressure/inspiratory fraction of oxygen tables (50%) or decremental positive end-expiratory pressure trials (20%). Neuro-muscular blockers were widely used, although routinely by only 3.3%. High-frequency oscillatory ventilation (10%) and inhaled nitric oxide (13.3%) were rarely used. None used oesophageal manometry. Recruitment manoeuvres were used 'often' by 26.7%. Equipment (90%) and protocols (80%) for prone position were common, with sessions mostly lasting 12-18 h. Conclusions Although variable, practice well reflected the available evidence. Proning was widely practiced with good availability of educational resources and protocolised care.
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Affiliation(s)
- Abhishek Jha
- Cardiothoracic Intensive Care Unit, St George's Hospitals NHS Foundation Trust, London, UK
| | | | | | - Kathleen Daly
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Guy Glover
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | | | - Duncan Wyncoll
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Peter Sherren
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Chris Langrish
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Chris Meadows
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Andrew Retter
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Richard Paul
- Guy's and Saint Thomas' NHS Foundation Trust, London, UK
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Prikhodko VA, Selizarova NO, Okovityi SV. [Molecular mechanisms for hypoxia development and adaptation to it. Part I]. Arkh Patol 2021; 83:52-61. [PMID: 33822555 DOI: 10.17116/patol20218302152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypoxia is a typical pathological process characterized by the occurrence of oxygen deficiency in tissues and cells and accompanied by the development of immediate and delayed compensatory and adaptive reactions. Reprogramming of the mitochondrial electron transport chain (ETC) function is one the most essential regulatory mechanisms that allow for immediate adaptation to hypoxia. Succinic acid, or succinate, is involved in this process not only as one of the intermediates of the tricarboxylic acid (TAC) cycle, but also as a signaling molecule. In this connection, the purpose of this review was to systematize the available data on the molecular mechanisms for the development of hypoxia and its adaptation at the ETC/TAC coupling site, as well as on the role of succinic acid in these processes.
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Affiliation(s)
- V A Prikhodko
- Saint Petersburg State Chemical and Pharmaceutical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - N O Selizarova
- Saint Petersburg State Chemical and Pharmaceutical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - S V Okovityi
- Saint Petersburg State Chemical and Pharmaceutical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
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25
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Improving Prone Positioning for Severe Acute Respiratory Distress Syndrome during the COVID-19 Pandemic. An Implementation-Mapping Approach. Ann Am Thorac Soc 2021; 18:300-307. [PMID: 33522870 PMCID: PMC7869786 DOI: 10.1513/annalsats.202005-571oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Rationale: Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS), a feature of severe coronavirus disease 2019 (COVID-19). Despite this, most patients with ARDS do not receive this lifesaving therapy.Objectives: To identify determinants of prone-positioning use, to develop specific implementation strategies, and to incorporate strategies into an overarching response to the COVID-19 crisis.Methods: We used an implementation-mapping approach guided by implementation-science frameworks. We conducted semistructured interviews with 30 intensive care unit (ICU) clinicians who staffed 12 ICUs within the Penn Medicine Health System and the University of Michigan Medical Center. We performed thematic analysis using the Consolidated Framework for Implementation Research. We then conducted three focus groups with a task force of ICU leaders to develop an implementation menu, using the Expert Recommendations for Implementing Change framework. The implementation strategies were adapted as part of the Penn Medicine COVID-19 pandemic response.Results: We identified five broad themes of determinants of prone positioning, including knowledge, resources, alternative therapies, team culture, and patient factors, which collectively spanned all five Consolidated Framework for Implementation Research domains. The task force developed five specific implementation strategies, including educational outreach, learning collaborative, clinical protocol, prone-positioning team, and automated alerting, elements of which were rapidly implemented at Penn Medicine.Conclusions: We identified five broad themes of determinants of evidence-based use of prone positioning for severe ARDS and several specific strategies to address these themes. These strategies may be feasible for rapid implementation to increase use of prone positioning for severe ARDS with COVID-19.
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Ding H, Li Y, Li X, Liu X, Chen S, Liu M, Zeng H. Treatment with 7% and 10% CO 2 enhanced expression of IL-1β, TNF-α, and IL-6 in hypoxic cultures of human whole blood. J Int Med Res 2021; 48:300060520912105. [PMID: 32264730 PMCID: PMC7144675 DOI: 10.1177/0300060520912105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective This study investigated whether hypercapnia influenced the inflammatory response of hypoxic blood. Methods Human whole blood was cultured with 0.2% oxygen (O2) and treated with 5%, 7%, or 10% carbon dioxide (CO2). Interleukin (IL)-1β, tumor necrosis factor (TNF)-α, and IL-6 were evaluated in whole blood cultures. Reactive oxygen species (ROS) production and expression levels of caspase-1 and IL-1β were evaluated in THP-1 monocytic cells. Results IL-1β, TNF-α, and IL-6 levels were higher in the hypoxia + 7% CO2 group than in the hypoxia + 5% CO2 group. The hypoxia + 10% CO2 group had the highest IL-1β, TNF-α, and IL-6 levels, compared with the hypoxia + 7% CO2 and hypoxia + 5% CO2 groups. Expression levels of IL-1β, TNF-α, and IL-6 were significantly negatively correlated with pH levels in the cell culture medium. Treatment with 7% and 10% CO2 increased the production of ROS and the expression of caspase-1 and IL-1β in hypoxia-activated THP-1 cells. Conclusions High levels of CO2 treatment increased expression levels of IL-1β, TNF-α, and IL-6 in hypoxic whole blood cultures. High levels of CO2-induced ROS overproduction and NLRP3 inflammasome activation in monocytes may comprise a target to mitigate the inflammatory response of hypoxic blood.
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Affiliation(s)
- Hongguang Ding
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ya Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Medicine, South China University of Technology, Guangzhou, China
| | - Xusheng Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xinqiang Liu
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shenglong Chen
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Mengting Liu
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hongke Zeng
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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27
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Tarazan N, Alshehri M, Sharif S, Al Duhailib Z, Møller MH, Belley-Cote E, Alshahrani M, Centofanti J, McIntyre L, Baw B, Meade M, Alhazzani W. Neuromuscular blocking agents in acute respiratory distress syndrome: updated systematic review and meta-analysis of randomized trials. Intensive Care Med Exp 2020; 8:61. [PMID: 33095344 PMCID: PMC7582438 DOI: 10.1186/s40635-020-00348-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/29/2020] [Indexed: 12/18/2022] Open
Abstract
Purpose Existing clinical practice guidelines support the use of neuromuscular blocking agents (NMBA) in acute respiratory distress syndrome (ARDS); however, a recent large randomized clinical trial (RCT) has questioned this practice. Therefore, we updated a previous systematic review to determine the efficacy and safety of NMBAs in ARDS. Methods We searched MEDLINE, EMBASE (October 2012 to July 2019), the Cochrane (Central) database, and clinical trial registries (ClinicalTrials.gov, ISRCTN Register, and WHO ICTRP) for RCTs comparing the effects of NMBA as a continuous infusion versus placebo or no NMBA infusion (but allowing intermittent NMBA boluses) on patient-important outcomes for adults with ARDS. Two independent reviewers assessed the methodologic quality of the primary studies and abstracted data. Results Seven RCTs, including four new RCTs, met eligibility criteria for this review. These trials enrolled 1598 patients with moderate to severe ARDS at centers in the USA, France, and China. All trials assessed short-term continuous infusions of cisatracurium or vecuronium. The pooled estimate for mortality outcomes showed significant statistical heterogeneity, which was only explained by a subgroup analysis by depth of sedation in the control arm. A continuous NMBA infusion did not improve mortality when compared to a light sedation strategy with no NMBA infusion (relative risk [RR] 0.99; 95% CI 0.86–1.15; moderate certainty; P = 0.93). On the other hand, continuous NMBA infusion reduced mortality when compared to deep sedation with as needed NMBA boluses (RR 0.71; 95% CI 0.57–0.89; low certainty; P = 0.003). Continuous NMBA infusion reduced the rate of barotrauma (RR 0.55; 95% CI 0.35–0.85, moderate certainty; P = 0.008) across eligible trials, but the effect on ventilator-free days, duration of mechanical ventilation, and ICU-acquired weakness was uncertain. Conclusions Inconsistency in study methods and findings precluded the pooling of all trials for mortality. In a pre-planned sensitivity analysis, the impact of NMBA infusion on mortality depends on the strategy used in the control arm, showing reduced mortality when compared to deep sedation, but no effect on mortality when compared to lighter sedation. In both situations, a continuous NMBA infusion may reduce the risk of barotrauma, but the effects on other patient-important outcomes remain unclear. Future research, including an individual patient data meta-analysis, could help clarify some of the observed findings in this updated systematic review.
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Affiliation(s)
- Nehal Tarazan
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Moayad Alshehri
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Internal Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Zainab Al Duhailib
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Ben Faisal University, Dammam, Saudi Arabia
| | - John Centofanti
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Lauralyn McIntyre
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Maureen Meade
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada.
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28
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Rowan CM, Klein MJ, Hsing DD, Dahmer MK, Spinella PC, Emeriaud G, Hassinger AB, Piñeres-Olave BE, Flori HR, Haileselassie B, Lopez-Fernandez YM, Chima RS, Shein SL, Maddux AB, Lillie J, Izquierdo L, Kneyber MCJ, Smith LS, Khemani RG, Thomas NJ, Yehya N. Early Use of Adjunctive Therapies for Pediatric Acute Respiratory Distress Syndrome: A PARDIE Study. Am J Respir Crit Care Med 2020; 201:1389-1397. [PMID: 32130867 DOI: 10.1164/rccm.201909-1807oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rationale: Few data exist to guide early adjunctive therapy use in pediatric acute respiratory distress syndrome (PARDS).Objectives: To describe contemporary use of adjunctive therapies for early PARDS as a framework for future investigations.Methods: This was a preplanned substudy of a prospective, international, cross-sectional observational study of children with PARDS from 100 centers over 10 study weeks.Measurements and Main Results: We investigated six adjunctive therapies for PARDS: continuous neuromuscular blockade, corticosteroids, inhaled nitric oxide (iNO), prone positioning, high-frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation. Almost half (45%) of children with PARDS received at least one therapy. Variability was noted in the median starting oxygenation index of each therapy; corticosteroids started at the lowest oxygenation index (13.0; interquartile range, 7.6-22.0) and HFOV at the highest (25.7; interquartile range, 16.7-37.3). Continuous neuromuscular blockade was the most common, used in 31%, followed by iNO (13%), corticosteroids (10%), prone positioning (10%), HFOV (9%), and extracorporeal membrane oxygenation (3%). Steroids, iNO, and HFOV were associated with comorbidities. Prone positioning and HFOV were more common in middle-income countries and less frequently used in North America. The use of multiple ancillary therapies increased over the first 3 days of PARDS, but there was not an easily identifiable pattern of combination or order of use.Conclusions: The contemporary description of prevalence, combinations of therapies, and oxygenation threshold for which the therapies are applied is important for design of future studies. Region of the world, income, and comorbidities influence adjunctive therapy use and are important variables to include in PARDS investigations.
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Affiliation(s)
- Courtney M Rowan
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, Indiana
| | - Margaret J Klein
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles and University of Southern California, Los Angeles, California
| | - Deyin Doreen Hsing
- Department of Pediatrics, New York Presbyterian Hospital and Weill Cornell Medical College, New York, New York
| | - Mary K Dahmer
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Guillaume Emeriaud
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montreal, Quebec, Canada
| | - Amanda B Hassinger
- Division of Pediatric Critical Care, Department of Pediatrics, Oishei Children's Hospital and University of Buffalo, Buffalo, New York
| | | | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Bereketeab Haileselassie
- Division of Pediatric Critical Care, Department of Pediatrics, Stanford University, Palo Alto, California
| | | | - Ranjit S Chima
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Aline B Maddux
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado, Aurora, Colorado
| | - Jon Lillie
- Evelina London Children's Hospital, London, United Kingdom
| | - Ledys Izquierdo
- Department of Pediatrics, Hospital Militar Central, Bogotá, Colombia
| | - Martin C J Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital and University of Groningen, Groningen, the Netherlands
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles and University of Southern California, Los Angeles, California
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, Pennsylvania and
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
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29
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Ding HG, Li Y, Li XS, Liu XQ, Wang KR, Wen MY, Jiang WQ, Zeng HK. Hypercapnia promotes microglial pyroptosis via inhibiting mitophagy in hypoxemic adult rats. CNS Neurosci Ther 2020; 26:1134-1146. [PMID: 32666671 PMCID: PMC7564198 DOI: 10.1111/cns.13435] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 12/19/2022] Open
Abstract
Background Hypoxemia is a typical symptom of acute respiratory distress syndrome. To avoid pulmonary morbidity, low tidal volume ventilation is often applied. The ventilation strategy will certainly cause hypercapnia. This study aimed to explore whether hypercapnia would promote microglial pyroptosis via inhibiting mitophagy in adult rats with hypoxemia. Methods The cerebral oxygen extraction ratio (CERO2) and partial pressure of brain tissue oxygen (PbtO2) in a rat model of hypercapnia/hypoxemia were assessed. The reactive oxygen species (ROS) production and the expression of LC3‐II/I, p62, caspase‐1, gasdermin D‐N domains (GSDMD‐N), IL‐1β, and IL‐18 in microglial cells were detected. Results Hypercapnia decreased the PbtO2 levels of the hypoxic rats, which was further evidenced by the increased levels of CERO2. Expression levels of LC3‐II were reduced, while p62 expression was increased by hypercapnia in hypoxic microglia. Hypercapnia increased the production of ROS and the expression of caspase‐1, GSDMD‐N, IL‐1β, and IL‐18 in hypoxia‐activated microglia. Scavenging ROS inhibited microglial pyroptosis and expression of IL‐1β and IL‐18. Conclusions These results suggest that hypercapnia‐induced mitophagy inhibition may promote pyroptosis and enhance IL‐1β and IL‐18 release in hypoxia‐activated microglia.
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Affiliation(s)
- Hong-Guang Ding
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ya Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Medicine, South China University of Technology, Guangzhou, China
| | - Xu-Sheng Li
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xin-Qiang Liu
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Kang-Rong Wang
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Southern Medical University, Guangzhou, China
| | - Miao-Yun Wen
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wen-Qiang Jiang
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hong-Ke Zeng
- Department of Emergency and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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30
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Wu HP, Hu HC, Chu CM, Kao KC. The association between higher driving pressure and higher mortality in patients with pneumonia without acute respiratory distress syndrome. J Formos Med Assoc 2020; 120:204-211. [PMID: 32376124 DOI: 10.1016/j.jfma.2020.04.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 04/18/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE Recent studies reported that driving pressure has been associated with increased mortality in acute respiratory distress syndrome (ARDS) patients. We aimed to explore the association between 28-day mortality and driving pressure in patients with severe pneumonia without ARDS. METHODS In total, 207 non-ARDS patients with severe pneumonia were enrolled. Serial driving pressures were recorded daily for either 21 days or until ventilator support was no longer required. The relationships between all variables and 28-day mortality were analyzed using binary logistic regression analyses. RESULTS Non-survivors (56 patients) demonstrated high incidences of shock (55.4% vs. 24.5%, p < 0.001), acute renal failure (55.4% vs. 31.1%, p = 0.001), gastrointestinal bleeding (21.4% vs. 9.9%, p = 0.029), thrombocytopenia (53.6% vs. 23.2%, p < 0.001), jaundice (12.5% vs. 1.3%, p = 0.002), and driving pressure on Day 1 (19.9 ± 4.1 vs. 17.4 ± 4.5 cmH2O, p = 0.001). The ratio of arterial partial pressure of oxygen to fraction of inspired oxygen was lower in non-survivors than in survivors (281.5 ± 139.3 vs. 376.2 ± 211.9, p = 0.002). Regression analysis revealed that driving pressure was an independent factor associated with 28-day mortality (odds ratio, 1.110; 95% confidence interval, 1.013-1.217). CONCLUSION Driving pressure was associated with 28-day mortality in patients with severe pneumonia without ARDS.
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Affiliation(s)
- Huang-Pin Wu
- Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Han-Chung Hu
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chien-Ming Chu
- Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kuo-Chin Kao
- Chang Gung University College of Medicine, Taoyuan, Taiwan; Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.
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31
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Law AC, Forbath N, O’Donoghue S, Stevens JP, Walkey AJ. Hospital-Level Availability of Prone Positioning in Massachusetts ICUs. Am J Respir Crit Care Med 2020; 201:1006-1008. [PMID: 31899648 PMCID: PMC7159431 DOI: 10.1164/rccm.201910-2097le] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Anica C. Law
- Beth Israel Deaconess Medical CenterBoston, Massachusetts
| | | | | | | | - Allan J. Walkey
- Boston University School of MedicineBoston, Massachusettsand
- Boston University School of Public HealthBoston, Massachusetts
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32
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Artham S, Verma A, Newsome AS, Somanath PR. Patients with acute respiratory distress syndrome exhibit increased stromelysin1 activity in the blood samples. Cytokine 2020; 131:155086. [PMID: 32272349 DOI: 10.1016/j.cyto.2020.155086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 03/28/2020] [Accepted: 03/30/2020] [Indexed: 12/16/2022]
Abstract
Enzyme activity analyses in the blood are expected to be reliable, non-invasive diagnostic as well as prognostic markers to reflect disease progression in acute lung injury (ALI). The objective of the current study was to evaluate the enzymatic activity of stromelysin1 (matrix metalloprotease-3) in the plasma/serum samples collected from ALI patients compared to the samples collected from healthy controls. Gene expression omnibus (GEO) database analysis indicated a correlation between increased stromelysin1 gene expression and the incidence of ALI in various animal models. Our analysis of patient plasma/serum samples from healthy controls and ALI patients revealed a significant, 3-fold increase in stromelysin1 activity in ALI plasma/serum compared to healthy subjects with no difference in stromelysin1 activity between the serum and plasma samples. Interestingly, no significant difference in stromelysin1 activity between non-smoking and smoking subjects was observed. These findings provide fundamental information on the potential reliability of stromelysin1 activity analysis, combined with other biomarkers in development, in blood samples for the early detection of ALI.
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Affiliation(s)
- Sandeep Artham
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical Center, Augusta, GA 30912, United States
| | - Arti Verma
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical Center, Augusta, GA 30912, United States
| | - Andrea Sikora Newsome
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical Center, Augusta, GA 30912, United States
| | - Payaningal R Somanath
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical Center, Augusta, GA 30912, United States; Georgia Cancer Center, Vascular Biology Center and Department of Medicine, Augusta University, Augusta, GA 30912, United States.
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33
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Co I, Hyzy RC. Rescue Neuromuscular Blockade in Acute Respiratory Distress Syndrome Should Be Flat Dose. Crit Care Med 2020; 48:591-593. [PMID: 32205607 DOI: 10.1097/ccm.0000000000004198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ivan Co
- Both authors: Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
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34
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Buckley MS, Agarwal SK, Garcia-Orr R, Saggar R, MacLaren R. Comparison of Fixed-Dose Inhaled Epoprostenol and Inhaled Nitric Oxide for Acute Respiratory Distress Syndrome in Critically Ill Adults. J Intensive Care Med 2020; 36:466-476. [PMID: 32133901 DOI: 10.1177/0885066620906800] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Several reports have demonstrated similar effects on oxygenation between inhaled epoprostenol (iEPO) compared to inhaled nitric oxide (iNO) for acute respiratory distress syndrome (ARDS). Previous studies directly comparing oxygenation and clinical outcomes between iEPO and iNO exclusively in an adult ARDS patient population utilized a weight-based dosing strategy. The purpose of this study was to compare the clinical and economic impact between iNO and fixed-dosed iEPO for ARDS in adult intensive care unit (ICU) patients. METHODS This retrospective cohort study was conducted at a major academic medical center between January 1, 2014, and October 31, 2018. Patients ≥18 years of age with moderate-to-severe ARDS were included. The primary end point was to compare the mean change in partial arterial oxygen pressure to fraction of inspired oxygen (Pao 2: Fio 2) at 4 hours from baseline between iEPO and iNO. Other secondary aims were total acquisition drug costs, in-hospital mortality, ICU and hospital length of stay, and duration of mechanical ventilation. RESULTS A total of 239 patients were included with 139 (58.2%) and 100 (41.8%) in the iEPO and iNO groups, respectively. The mean change in Pao 2: Fio 2 at 4 hours from baseline in the iEPO and iNO groups were 31.4 ± 54.6 and 32.4 ± 42.7 mm Hg, respectively (P = .88). The responder rate at 4 hours was similar between iEPO and iNO groups (64.7% and 66.0%, respectively, P = .84). Clinical outcomes including mortality, overall hospital and ICU length of stay, and mechanical ventilation duration were similar between iEPO and iNO groups. Estimated annual cost-savings realized with iEPO was USD1 074 433. CONCLUSION Fixed-dose iEPO was comparable to iNO in patients with moderate-to-severe ARDS for oxygenation and ventilation parameters as well as clinical outcomes. Significant cost-savings were realized with iEPO use.
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Affiliation(s)
- Mitchell S Buckley
- 22386Banner-University Medical Center Phoenix, Department of Pharmacy, Phoenix, AZ, USA
| | - Sumit K Agarwal
- 22386Banner-University Medical Center Phoenix, Care Transformation, Phoenix, AZ, USA
| | - Roxanne Garcia-Orr
- 22386Banner-University Medical Center Phoenix, Department of Critical Care, Phoenix, AZ, USA
| | - Rajeev Saggar
- 22386Banner-University Medical Center Phoenix, Department of Critical Care, Phoenix, AZ, USA
| | - Robert MacLaren
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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35
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Patterns of Use of Adjunctive Therapies in Patients With Early Moderate to Severe ARDS: Insights From the LUNG SAFE Study. Chest 2020; 157:1497-1505. [PMID: 32088180 DOI: 10.1016/j.chest.2020.01.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/04/2019] [Accepted: 01/13/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adjunctive strategies are an important part of the management of ARDS. However, their application in clinical practice remains inconsistent. RESEARCH QUESTION We wished to determine the frequency and patterns of use of adjunctive strategies in patients with moderate to severe ARDS (Pao2/Fio2 [P/F ratio] < 150) enrolled into the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. STUDY DESIGN AND METHODS The LUNG SAFE study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted in 2014 in 459 ICUs from 50 countries. The primary objective of this substudy was to determine the frequency of use of widely available (neuromuscular blockade, prone position) adjuncts vs adjuncts requiring specialized equipment (extracorporeal membrane oxygenation, inhaled vasodilators, high-frequency ventilation) in patients in the first 48 h of moderate to severe ARDS (P/F ratio < 150). RESULTS Of 1,146 patients on invasive ventilation with moderate to severe ARDS, 811 patients (71%) received no adjunct within 48 h of ARDS onset. Of 335 (29%) that received adjunctive strategies, 252 (75%) received a single strategy, and 83 (25%) receiving more than one adjunct. Of ARDS nonsurvivors, 67% did not receive any adjunctive strategy in the first 48 h. Most patients (67%) receiving specialized adjuncts did not receive prone positioning or neuromuscular blockade. Patients that received adjuncts were more likely to have their ARDS recognized, be younger and sicker, have pneumonia, be more difficult to ventilate, and be in a European high-income country than those that did not receive adjuncts. INTERPRETATION Three in 10 patients with moderate to severe ARDS, and only one-third of nonsurvivors, received adjunctive strategies over the first 48 h of ARDS. A more consistent and evidence-driven approach to adjunct use may reduce costs and improve outcomes in patients with moderate to severe ARDS. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02010073; URL: www.clinicaltrials.gov.
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The Cost-Effectiveness of Interventions to Increase Utilization of Prone Positioning for Severe Acute Respiratory Distress Syndrome. Crit Care Med 2020; 47:e198-e205. [PMID: 30779719 DOI: 10.1097/ccm.0000000000003617] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Despite strong evidence supporting proning in acute respiratory distress syndrome, few eligible patients receive it. This study determines the cost-effectiveness of interventions to increase utilization of proning for severe acute respiratory distress syndrome. DESIGN We created decision trees to model severe acute respiratory distress syndrome from ICU admission through death (societal perspective) and hospital discharge (hospital perspective). We assumed patients received low tidal volume ventilation. We used short-term outcome estimates from the PROSEVA trial and longitudinal cost and benefit data from cohort studies. In probabilistic sensitivity analyses, we used distributions for each input that included the fifth to 95th percentile of its CI. SETTING ICUs that care for patients with acute respiratory distress syndrome. SUBJECTS Patients with moderate to severe acute respiratory distress syndrome. INTERVENTIONS The implementation of a hypothetical intervention to increase the appropriate utilization of prone positioning. MEASUREMENTS AND MAIN RESULTS In the societal perspective model, an intervention that increased proning utilization from 16% to 65% yielded an additional 0.779 (95% CI, 0.088-1.714) quality-adjusted life years at an additional long-term cost of $31,156 (95% CI, -$158 to $92,179) (incremental cost-effectiveness ratio = $38,648 per quality-adjusted life year [95% CI, $1,695-$98,522]). If society was willing to pay $100,000 per quality-adjusted life year, any intervention costing less than $51,328 per patient with moderate to severe acute respiratory distress syndrome would represent good value. From a hospital perspective, the intervention yielded 0.072 (95% CI, 0.008-0.147) more survivals-to-discharge at a cost of $5,242 (95% CI, -$19,035 to $41,019) (incremental cost-effectiveness ratio = $44,615 per extra survival [95% CI, -$250,912 to $558,222]). If hospitals were willing to pay $100,000 per survival-to-discharge, any intervention costing less than $5,140 per patient would represent good value. CONCLUSIONS Interventions that increase utilization of proning would be cost-effective from both societal and hospital perspectives under many plausible cost and benefit assumptions.
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Abstract
OBJECTIVES Prior studies investigating hospital mechanical ventilation volume-outcome associations have had conflicting findings. Volume-outcome relationships within contemporary mechanical ventilation practices are unclear. We sought to determine associations between hospital mechanical ventilation volume and patient outcomes. DESIGN Retrospective cohort study. SETTING The California Patient Discharge Database 2016. PATIENTS Adult nonsurgical patients receiving mechanical ventilation. INTERVENTIONS The primary outcome was hospital death with secondary outcomes of tracheostomy and 30-day readmission. We used multivariable generalized estimating equations to determine the association between patient outcomes and hospital mechanical ventilation volume quartile. MEASUREMENTS AND MAIN RESULTS We identified 51,689 patients across 274 hospitals who required mechanical ventilation in California in 2016. 38.2% of patients died in the hospital with 4.4% receiving a tracheostomy. Among survivors, 29.5% required readmission within 30 days of discharge. Patients admitted to high versus low volume hospitals had higher odds of death (quartile 4 vs quartile 1 adjusted odds ratio, 1.40; 95% CI, 1.17-1.68) and tracheostomy (quartile 4 vs quartile 1 adjusted odds ratio, 1.58; 95% CI, 1.21-2.06). However, odds of 30-day readmission among survivors was lower at high versus low volume hospitals (quartile 4 vs quartile 1 adjusted odds ratio, 0.77; 95% CI, 0.67-0.89). Higher hospital mechanical ventilation volume was weakly correlated with higher hospital risk-adjusted mortality rates (ρ = 0.16; p = 0.008). These moderately strong observations were supported by multiple sensitivity analyses. CONCLUSIONS Contrary to previous studies, we observed worse patient outcomes at higher mechanical ventilation volume hospitals. In the setting of increasing use of mechanical ventilation and changes in mechanical ventilation practices, multiple mechanisms of worse outcomes including resource strain are possible. Future studies investigating differences in processes of care between high and low volume hospitals are necessary.
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POINT: Should Computerized Protocols Replace Physicians for Managing Mechanical Ventilation? Yes. Chest 2019; 154:479-481. [PMID: 30195341 DOI: 10.1016/j.chest.2018.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 11/22/2022] Open
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Neuromuscular blocking agents for adult patients with acute respiratory distress syndrome: A meta-analysis of randomized controlled trials. J Trauma Acute Care Surg 2019; 85:1102-1109. [PMID: 30462621 DOI: 10.1097/ta.0000000000002057] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To explore the effect of neuromuscular blocking agents (NMBAs) on adult patients with acute respiratory distress syndrome (ARDS) by meta-analysis. METHODS Three databases including Cochrane central register of controlled trials, PubMed, and Wanfang Data were searched to find relevant articles. We included randomized controlled trials that evaluated NMBAs compared with placebo or usual treatment in adult patients with ARDS. RESULTS Five trials totaling 551 patients were identified eligible for inclusion. All the five trials were protective ventilation strategies based. All patients (the ratio of partial pressure of arterial oxygen/fraction of inspired oxygen ≤ 200 mm Hg) met American-European Consensus Conference or the Berlin definition oxygenation criteria for ARDS. Neuromuscular blocking agents significantly reduced intensive care unit mortality (relative risk, 0.73; 95% confidence intervals [CI], 0.58-0.93; p = 0.009; I = 0.0%; 4 trials, 455 patients) and 21- to 28-day mortality (relative risk, 0.63; 95% CI, 0.49-0.82; p = 0.001; I = 0.0%; 4 trials, 527 patients). At 48 hours, NMBAs improved oxygenation (weighted mean differences [WMD], 27.98; 95% CI, 7.45-48.51; p = 0.008; I = 44.2%; 4 trials, 212 patients). However, NMBAs have no effect on reduction of oxygenation at 24 hours (WMD, 26.83; 95% CI, -5.89 to 59.55; p = 0.108; I = 82.4%; 4 trials, 447 patients), and plateau pressure (WMD, 0.43; 95% CI, -0.46 to 1.31; p = 0.345; 4 trials, 455 patients) as well as positive end expiratory pressure (WMD, 0.10; 95% CI, -0.47 to 0.67; p = 0.73; 4 trials, 455 patients) at 48 hours. CONCLUSION Protective ventilation strategies based NMBAs treatment reduces mortality in patients with moderate to severe ARDS. LEVEL OF EVIDENCE Systematic reviews & meta-analysis, level III.
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Stiff A, Harrison R, Palatnik A. Case report of massive hemoptysis in pregnancy requiring veno-venous extracorporeal membrane oxygenation. J Obstet Gynaecol Res 2019; 45:2452-2455. [PMID: 31486147 DOI: 10.1111/jog.14110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/14/2019] [Indexed: 12/01/2022]
Abstract
Hemoptysis in pregnancy is rare and can be life-threatening. This case describes management of hemoptysis in pregnancy requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patient presented with massive hemoptysis in respiratory failure at 26 weeks gestation. VV-ECMO was utilized for maternal stability due to severe hypoxia from lung parenchymal damage. An extensive work-up for hemoptysis returned negative except for an elevated Bordetella pertussis IgG antibody. The patient was delivered via cesarean section with a complicated post-partum course. She and the infant were discharged in stable condition after long hospital stays. Prior publications describing VV-ECMO use in pregnancy are limited to treatment of respiratory infections such as influenza or pneumonia. This case is the first in the literature to describe VV-ECMO utilization for hemoptysis in pregnancy, specifically, and demonstrates its significant benefit in cases of respiratory failure due to hemoptysis.
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Affiliation(s)
- Alyssa Stiff
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Refractory Hypoxemia and Acute Respiratory Distress Syndrome Adjunctive Therapies: An Open Question? Ann Am Thorac Soc 2019; 14:1768-1769. [PMID: 29192824 DOI: 10.1513/annalsats.201707-547ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Ji M, Hong X, Chen M, Chen T, Jia Y, Zhu J, Wu X, Huang X, Zhang N. Effects of SI and PCV on respiratory mechanics, early central drive and hemodynamics in patients with ARDS. Exp Ther Med 2019; 17:2708-2714. [PMID: 30906461 PMCID: PMC6425255 DOI: 10.3892/etm.2019.7218] [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: 09/05/2018] [Accepted: 01/24/2019] [Indexed: 12/04/2022] Open
Abstract
Effects of sustained inflation (SI) and pressure- controlled ventilation (PCV) on respiratory mechanics, early central drive, and hemodynamics in patients with acute respiratory distress syndrome (ARDS) were investigated and compared. A retrospective analysis of 26 patients with ARDS, who were admitted to the Yiwu Central Hospital from March 2015 to March 2016, was performed. According to the ventilation method adopted by the patients with ARDS, 13 patients who received SI treatment were included in the SI group and 13 patients who received PCV treatment were included in the PCV group. The condition of central drive of the patients in the two groups was recorded and calculated continuously before and after recruitment maneuver (RM), the changes of each indicator of the respiratory function and hemodynamics were recorded and calculated before and after RM at 1, 10, 20 and 30 min. The differences were not statistically significant when comparing PIP, Pplate and Crs in patients in the SI group and the PCV group before RM with those after RM at 1, 10, 20 and 30 min (P>0.05), the differences were not statistically significant when comparing heart rate and mean arterial pressure in patients in the SI group and the PCV group before RM with those after RM at 1, 10, 20 and 30 min (P>0.05). Ηowever, central venous pressure in patients in the SI group after RM at 10 and 20 min was significantly higher than that in the PCV group, and the differences were statistically significant (P<0.05). VT/RMS, VE/RMS and ΔPdi/RMS in the SI group and the PCV group after RM were significantly higher than those before RM, and the differences were statistically significant (P<0.05). There was little difference in the effect between SI and PCV on respiratory mechanics, early central drive and hemodynamics in patients with ARDS, and both mechanical ventilation methods enhanced the effect of central-mechanical-ventilation coupling after RM. Therefore, the two mechanical ventilation methods, SI and PCV, were equally available for patients with ARDS.
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Affiliation(s)
- Mingxia Ji
- Department of Emergency, Yiwu Central Hospital, Yiwu, Zhejiang 320000, P.R. China
| | - Xiaofei Hong
- Department of Science and Education, Yiwu Central Hospital, Yiwu, Zhejiang 320000, P.R. China
| | - Mengyan Chen
- Department of Emergency, Yiwu Central Hospital, Yiwu, Zhejiang 320000, P.R. China
| | - Tiejiang Chen
- Department of Emergency, Yiwu Central Hospital, Yiwu, Zhejiang 320000, P.R. China
| | - Yi'An Jia
- Department of Emergency, Yiwu Central Hospital, Yiwu, Zhejiang 320000, P.R. China
| | - Jinjiang Zhu
- Department of Emergency, Yiwu Central Hospital, Yiwu, Zhejiang 320000, P.R. China
| | - Xionglin Wu
- Department of Emergency, Yiwu Central Hospital, Yiwu, Zhejiang 320000, P.R. China
| | - Xiaoying Huang
- Department of Emergency, Yiwu Central Hospital, Yiwu, Zhejiang 320000, P.R. China
| | - Ning Zhang
- Department of ICU, Lishui People's Hospital, Lishui, Zhejiang 323000, P.R. China
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Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Med 2018; 46:1820-1831. [PMID: 30247273 PMCID: PMC6277052 DOI: 10.1097/ccm.0000000000003406] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Despite decades of research, the acute respiratory distress syndrome remains associated with significant morbidity and mortality. This Concise Definitive Review provides a practical and evidence-based summary of treatments in addition to low tidal volume ventilation and their role in the management of severe respiratory failure in acute respiratory distress syndrome. DATA SOURCES We searched the PubMed database for clinical trials, observational studies, and review articles describing treatment adjuncts in acute respiratory distress syndrome patients, including high positive end-expiratory pressure strategies, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade, prone positioning, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, glucocorticoids, and renal replacement therapy. STUDY SELECTION AND DATA EXTRACTION Results were reviewed by the primary author in depth. Disputed findings and conclusions were then reviewed with the other authors until consensus was achieved. DATA SYNTHESIS Severe respiratory failure in acute respiratory distress syndrome may present with refractory hypoxemia, severe respiratory acidosis, or elevated plateau airway pressures despite lung-protective ventilation according to acute respiratory distress syndrome Network protocol. For severe hypoxemia, first-line treatment adjuncts include high positive end-expiratory pressure strategies, recruitment maneuvers, neuromuscular blockade, and prone positioning. For refractory acidosis, we recommend initial modest liberalization of tidal volumes, followed by neuromuscular blockade and prone positioning. For elevated plateau airway pressures, we suggest first decreasing tidal volumes, followed by neuromuscular blockade, modification of positive end-expiratory pressure, and prone positioning. Therapies such as inhaled pulmonary vasodilators, glucocorticoids, and renal replacement therapy have significantly less evidence in favor of their use and should be considered second line. Extracorporeal membrane oxygenation may be life-saving in selected patients with severe acute respiratory distress syndrome but should be used only when other alternatives have been applied. CONCLUSIONS Severe respiratory failure in acute respiratory distress syndrome often necessitates the use of treatment adjuncts. Evidence-based application of these therapies in acute respiratory distress syndrome remains a significant challenge. However, a rational stepwise approach with frequent monitoring for improvement or harm can be achieved.
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Affiliation(s)
- Vikram Fielding-Singh
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA
| | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Carolyn S. Calfee
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
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MacIntyre N. COUNTERPOINT: Should Computerized Protocols Replace Physicians for Managing Mechanical Ventilation? No. Chest 2018; 154:481-484. [DOI: 10.1016/j.chest.2018.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 11/16/2022] Open
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Newsome AS, Chastain DB, Watkins P, Hawkins WA. Complications and Pharmacologic Interventions of Invasive Positive Pressure Ventilation During Critical Illness. J Pharm Technol 2018; 34:153-170. [PMID: 34860978 DOI: 10.1177/8755122518766594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review the fundamentals of invasive positive pressure ventilation (IPPV) and the common complications and associated pharmacotherapeutic management in order to provide opportunities for pharmacists to improve patient outcomes. Data Sources: A MEDLINE literature search (1950-December 2017) was performed using the key search terms invasive positive pressure ventilation, mechanical ventilation, pharmacist, respiratory failure, ventilator associated organ dysfunction, ventilator associated pneumonia, ventilator bundles, and ventilator liberation. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language original research and review reports were evaluated. Data Synthesis: IPPV is a common supportive care measure for critically ill patients. While lifesaving, IPPV is associated with significant complications including ventilator-associated pneumonia, sinusitis, organ dysfunction, and hemodynamic alterations. Optimization of pain and sedation management provides an opportunity for pharmacists to directly affect IPPV exposure. A number of pharmacotherapeutic interventions are related directly to prophylaxis against IPPV-associated adverse events or aimed at reduction of duration of IPPV. Conclusions: Enhanced knowledge of the common complications, associated pharmacotherapy, and monitoring strategies facilitate the pharmacist's ability to provide increased pharmacotherapeutic insight in a multidisciplinary intensive care unit setting.
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Affiliation(s)
- Andrea Sikora Newsome
- The University of Georgia, Augusta, GA, USA.,Augusta University Medical Center, Augusta, GA, USA
| | | | | | - W Anthony Hawkins
- The University of Georgia, Augusta, GA, USA.,The University of Georgia-Albany, GA, USA
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Hamilton-DONATE: a city-wide pilot observational study of the ICU management of deceased organ donors. Can J Anaesth 2018; 65:1110-1119. [PMID: 29987806 DOI: 10.1007/s12630-018-1179-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/29/2018] [Accepted: 04/18/2018] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Improving the medical care of deceased organ donors to increase transplant rates and improve allograft function requires an understanding of the current epidemiology and clinical practices of deceased donation within intensive care units (ICUs). Herein, we report the results of our investigation into the feasibility of a multicentre prospective cohort study addressing the afformentioned issues. METHODS We conducted a 12-month prospective observational cohort study in six ICUs and one coronary care unit in Hamilton, Canada. We included consecutive children and adults following consent for deceased organ donation (including neurologic determination of death [NDD] or donation after circulatory death [DCD]). Intensive care unit research staff recorded donor management data from hospital records, extending from one day prior to the consent for organ donation up to the time of organ retrieval. The provincial Organ Donation Organization (ODO) supplemented these data and, additionally, provided data on corresponding organ recipients. We identified, evaluated, and measured three potential obstacles to the feasibility of a national cohort study: obtaining authorization to implement the study with a waiver of research consent, accessibility of transplant recipient data, and the time required to complete very detailed case report forms (CRFs), with valuable lessons learned for implementation in future projects. RESULTS The local Research Ethics Board and the ODO Privacy Office both authorized the recording of donor and recipient study data with a waiver of research consent. Sixty-seven consecutive consented donors were included (31 NDD and 36 DCD donors); 50 of them provided 144 organs for transplantation to 141 recipients. We identified the age and sex of the recipients as well as the location and date of transplant for all organ recipients in Ontario; however, we obtained no recipient data for six organs transported outside of Ontario. Intensive care unit research staff estimated that future CRF completion will require five to seven hours per patient. CONCLUSION The Hamilton-DONATE pilot study supports the feasibility of a larger cohort study to describe the epidemiology and clinical practices related to deceased donor care in Canada. TRIAL REGISTRATION wwwclinicaltrials.gov (NCT02902783). Registered 16 September 2016.
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Pham T, Telias I, Piraino T, Yoshida T, Brochard LJ. Asynchrony Consequences and Management. Crit Care Clin 2018; 34:325-341. [DOI: 10.1016/j.ccc.2018.03.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ferguson ND, Guérin C. Adjunct and rescue therapies for refractory hypoxemia: prone position, inhaled nitric oxide, high frequency oscillation, extra corporeal life support. Intensive Care Med 2018; 44:1528-1531. [PMID: 29349687 DOI: 10.1007/s00134-017-5040-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 12/22/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada.,Toronto General Research Institute, Toronto, Canada
| | - Claude Guérin
- Réanimation médicale, Hôpital de la Croix Rousse, Hospices civils de Lyon, Lyon, France. .,Université de Lyon, Lyon, France. .,INSERM 955, Créteil, France.
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