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Barrios EL, Mazer MB, McGonagill PW, Bergmann CB, Goodman MD, Gould RW, Rao M, Polcz VE, Davis RJ, Del Toro DE, Dirain ML, Dram A, Hale LO, Heidarian M, Kim CY, Kucaba TA, Lanz JP, McCray AE, Meszaros S, Miles S, Nelson CR, Rocha IL, Silva EE, Ungaro RF, Walton AH, Xu J, Zeumer-Spataro L, Drewry AM, Liang M, Bible LE, Loftus TJ, Turnbull IR, Efron PA, Remy KE, Brakenridge SC, Badovinac VP, Griffith TS, Moldawer LL, Hotchkiss RS, Caldwell CC. Adverse outcomes and an immunosuppressed endotype in septic patients with reduced IFN-γ ELISpot. JCI Insight 2024; 9:e175785. [PMID: 38100268 PMCID: PMC10906237 DOI: 10.1172/jci.insight.175785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUNDSepsis remains a major clinical challenge for which successful treatment requires greater precision in identifying patients at increased risk of adverse outcomes requiring different therapeutic approaches. Predicting clinical outcomes and immunological endotyping of septic patients generally relies on using blood protein or mRNA biomarkers, or static cell phenotyping. Here, we sought to determine whether functional immune responsiveness would yield improved precision.METHODSAn ex vivo whole-blood enzyme-linked immunosorbent spot (ELISpot) assay for cellular production of interferon γ (IFN-γ) was evaluated in 107 septic and 68 nonseptic patients from 5 academic health centers using blood samples collected on days 1, 4, and 7 following ICU admission.RESULTSCompared with 46 healthy participants, unstimulated and stimulated whole-blood IFN-γ expression was either increased or unchanged, respectively, in septic and nonseptic ICU patients. However, in septic patients who did not survive 180 days, stimulated whole-blood IFN-γ expression was significantly reduced on ICU days 1, 4, and 7 (all P < 0.05), due to both significant reductions in total number of IFN-γ-producing cells and amount of IFN-γ produced per cell (all P < 0.05). Importantly, IFN-γ total expression on days 1 and 4 after admission could discriminate 180-day mortality better than absolute lymphocyte count (ALC), IL-6, and procalcitonin. Septic patients with low IFN-γ expression were older and had lower ALCs and higher soluble PD-L1 and IL-10 concentrations, consistent with an immunosuppressed endotype.CONCLUSIONSA whole-blood IFN-γ ELISpot assay can both identify septic patients at increased risk of late mortality and identify immunosuppressed septic patients.TRIAL REGISTRYN/A.FUNDINGThis prospective, observational, multicenter clinical study was directly supported by National Institute of General Medical Sciences grant R01 GM-139046, including a supplement (R01 GM-139046-03S1) from 2022 to 2024.
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Affiliation(s)
- Evan L. Barrios
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Monty B. Mazer
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Patrick W. McGonagill
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Christian B. Bergmann
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- University Hospital Ulm, Clinic for Trauma Surgery, Hand, Plastic, and Reconstructive Surgery Albert-Einstein-Allee 23, Ulm, Germany
| | - Michael D. Goodman
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Robert W. Gould
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Mahil Rao
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Valerie E. Polcz
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ruth J. Davis
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Drew E. Del Toro
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marvin L.S. Dirain
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Alexandra Dram
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lucas O. Hale
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Mohammad Heidarian
- Interdisciplinary Program in Immunology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Caleb Y. Kim
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Tamara A. Kucaba
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer P. Lanz
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ashley E. McCray
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sandra Meszaros
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sydney Miles
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Candace R. Nelson
- Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ivanna L. Rocha
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Elvia E. Silva
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ricardo F. Ungaro
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andrew H. Walton
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Julie Xu
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Leilani Zeumer-Spataro
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anne M. Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Muxuan Liang
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
- Department of Biostatistics, University of Florida College of Public Health and Health Professions and the University of Florida College of Medicine, Gainesville, Florida, USA
| | - Letitia E. Bible
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Tyler J. Loftus
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Isaiah R. Turnbull
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Philip A. Efron
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kenneth E. Remy
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Scott C. Brakenridge
- Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vladimir P. Badovinac
- Interdisciplinary Program in Immunology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Experimental Pathology PhD Program, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Thomas S. Griffith
- Department of Urology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Center for Immunology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
| | - Lyle L. Moldawer
- Sepsis and Critical Illness Research Center, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Richard S. Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles C. Caldwell
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Bonfanti NP, Mohr NM, Willms DC, Bedimo RJ, Gundert E, Goff KL, Kulstad EB, Drewry AM. Core Warming of Coronavirus Disease 2019 Patients Undergoing Mechanical Ventilation: A Pilot Study. Ther Hypothermia Temp Manag 2023; 13:225-229. [PMID: 37527424 DOI: 10.1089/ther.2023.0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Fever is a recognized protective factor in patients with sepsis, and growing data suggest beneficial effects on outcomes in sepsis with elevated temperature, with a recent pilot randomized controlled trial (RCT) showing lower mortality by warming afebrile sepsis patients in the intensive care unit (ICU). The objective of this prospective single-site RCT was to determine if core warming improves respiratory physiology of mechanically ventilated patients with coronavirus disease 2019 (COVID-19), allowing earlier weaning from ventilation, and greater overall survival. A total of 19 patients with mean age of 60.5 (±12.5) years, 37% female, mean weight 95.1 (±18.6) kg, and mean body mass index 34.5 (±5.9) kg/m2 with COVID-19 requiring mechanical ventilation were enrolled from September 2020 to February 2022. Patients were randomized 1:1 to standard of care or to receive core warming for 72 hours through an esophageal heat exchanger commonly utilized in critical care and surgical patients. The maximum target temperature was 39.8°C. A total of 10 patients received usual care and 9 patients received esophageal core warming. After 72 hours of warming, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratios were 197 (±32) and 134 (±13.4), cycle thresholds were 30.8 (±6.4) and 31.4 (±3.2), ICU mortalities were 40% and 44%, 30-day mortalities were 30% and 22%, and mean 30-day ventilator-free days were 11.9 (±12.6) and 6.8 (±10.2) for standard of care and warmed patients, respectively (p = NS). This pilot study suggests that core warming of patients with COVID-19 undergoing mechanical ventilation is feasible and appears safe. Optimizing time to achieve febrile-range temperature may require a multimodal temperature management strategy to further evaluate effects on outcome. ClinicalTrials.gov Identifier: NCT04494867.
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Affiliation(s)
- Nathaniel P Bonfanti
- Department of Emergency Medicine, University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - David C Willms
- Department of Critical Care, Sharp Memorial Hospital, San Diego, California, USA
| | - Roger J Bedimo
- Department of Internal Medicine, Division of Infectious Disease, VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emily Gundert
- Department of Emergency Medicine, University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - Kristina L Goff
- Department of Anesthesiology, University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - Erik B Kulstad
- Department of Emergency Medicine, University of Texas at Southwestern Medical Center, Dallas, Texas, USA
| | - Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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3
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Affiliation(s)
- Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO
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4
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Fuller BM, Pappal RD, Mohr NM, Roberts BW, Faine B, Yeary J, Sewatsky T, Johnson NJ, Driver BE, Ablordeppey E, Drewry AM, Wessman BT, Yan Y, Kollef MH, Carpenter CR, Avidan MS. Awareness With Paralysis Among Critically Ill Emergency Department Patients: A Prospective Cohort Study. Crit Care Med 2022; 50:1449-1460. [PMID: 35866657 PMCID: PMC10040234 DOI: 10.1097/ccm.0000000000005626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence. DESIGN An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial. SETTING The ED of three academic medical centers. PATIENTS Mechanically ventilated adult patients that received neuromuscular blockers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01). CONCLUSIONS AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.
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Affiliation(s)
- Brian M Fuller
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Ryan D Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Brett Faine
- Departments of Emergency Medicine and Pharmacy, Roy J. and Lucille A. Carver College of Medicine, University of Iowa College of Pharmacy, Iowa City, IA
| | - Julianne Yeary
- Emergency Department, Charles F. Knight Emergency and Trauma Center, Barnes Jewish Hospital, St. Louis, MO
| | - Thomas Sewatsky
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Nicholas J Johnson
- Departments of Emergency Medicine and Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington/Harborview Medical Center, Seattle, WA
| | - Brian E Driver
- Department of Emergency Medicine, University of Minnesota School of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Enyo Ablordeppey
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Departments of Anesthesiology and Emergency Medicine, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Division of Biostatistics, Washington University School of Medicine, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO
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Affiliation(s)
- Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO
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Ofoma UR, Drewry AM, Maddox TM, Boyle W, Deych E, Kollef M, Girotra S, Joynt Maddox KE. Outcomes of in-hospital cardiac arrest among hospitals with and without telemedicine critical care. Resuscitation 2022; 177:7-15. [PMID: 35724851 PMCID: PMC9296566 DOI: 10.1016/j.resuscitation.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/16/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Survival rates following in-hospital cardiac arrest (IHCA) are lower during nights and weekends (off-hours), as compared to daytime on weekdays (on-hours). Telemedicine Critical Care (TCC) may provide clinical support to improve IHCA outcomes, particularly during off-hours. OBJECTIVE To evaluate the association between hospital availability of TCC and IHCA survival. METHODS We identified 44,585 adults at 280 U.S. hospitals in the Get With The Guidelines® - Resuscitation registry who suffered IHCA in an Intensive Care Unit (ICU) or hospital ward between July 2017 and December 2019. We used 2-level hierarchical multivariable logistic regression to investigate whether TCC availability was associated with better survival, overall, and during on-hours (Monday-Friday 7:00 a.m.-10:59p.m.) vs. off-hours (Monday-Friday 11:00p.m.-6:59 a.m., and Saturday-Sunday, all day, and US national holidays). RESULTS 14,373 (32.2%) participants suffered IHCA at hospitals with TCC, and 27,032 (60.6%) occurred in an ICU. There was no difference between TCC and non-TCC hospitals in acute resuscitation survival rate or survival to discharge rates for either IHCA occurring in the ICU (acute survival odds ratio [OR] 1.02, 95% CI 0.92-1.15; survival to discharge OR 0.94 [0.83-1.07]) or outside of the ICU (acute survival OR 1.03 [0.91-1.17]; survival to discharge OR 0.99 [0.86-1.12]. Timing of cardiac arrest did not modify the association between TCC availability and acute resuscitation survival (P =.37 for interaction) or survival to discharge (P =.39 for interaction). CONCLUSIONS Hospital availability of TCC was not associated with improved outcomes for in-hospital cardiac arrest.
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Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA.
| | - Anne M Drewry
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Thomas M Maddox
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA; Healthcare Innovation Laboratory, BJC Healthcare and Washington University School of Medicine, St. Louis, MO, USA
| | - Walter Boyle
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Elena Deych
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Saket Girotra
- Division of Cardiovascular Diseases, Department of Medicine, University of Iowa Hospitals and Clinics and the Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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Drewry AM, Mohr NM, Ablordeppey EA, Dalton CM, Doctor RJ, Fuller B, Kollef MH, Hotchkiss RS. Therapeutic Hyperthermia Is Associated With Improved Survival in Afebrile Critically Ill Patients With Sepsis: A Pilot Randomized Trial. Crit Care Med 2022; 50:924-934. [PMID: 35120040 PMCID: PMC9133030 DOI: 10.1097/ccm.0000000000005470] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To test the hypothesis that forced-air warming of critically ill afebrile sepsis patients improves immune function compared to standard temperature management. DESIGN Single-center, prospective, open-label, randomized controlled trial. SETTING One thousand two hundred-bed academic medical center. PATIENTS Eligible patients were mechanically ventilated septic adults with: 1) a diagnosis of sepsis within 48 hours of enrollment; 2) anticipated need for mechanical ventilation of greater than 48 hours; and 3) a maximum temperature less than 38.3°C within the 24 hours prior to enrollment. Primary exclusion criteria included: immunologic diseases, immune-suppressing medications, and any existing condition sensitive to therapeutic hyperthermia (e.g., brain injury). The primary outcome was monocyte human leukocyte antigen (HLA)-DR expression, with secondary outcomes of CD3/CD28-induced interferon gamma (IFN-γ) production, mortality, and 28-day hospital-free days. INTERVENTIONS External warming using a forced-air warming blanket for 48 hours, with a goal temperature 1.5°C above the lowest temperature documented in the previous 24 hours. MEASUREMENTS AND MAIN RESULTS We enrolled 56 participants in the study. No differences were observed between the groups in HLA-DR expression (692 vs 2,002; p = 0.396) or IFN-γ production (31 vs 69; p = 0.678). Participants allocated to external warming had lower 28-day mortality (18% vs 43%; absolute risk reduction, 25%; 95% CI, 2-48%) and more 28-day hospital-free days (difference, 2.6 d; 95% CI, 0-11.6). CONCLUSIONS Participants randomized to external forced-air warming did not have a difference in HLA-DR expression or IFN-γ production. In this pilot study, however, 28-day mortality was lower in the intervention group. Future research should seek to better elucidate the impact of temperature modulation on immune and nonimmune organ failure pathways in sepsis.
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Affiliation(s)
- Anne M. Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Enyo A. Ablordeppey
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Catherine M. Dalton
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Rebecca J. Doctor
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Brian Fuller
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Marin H. Kollef
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Richard S. Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Ablordeppey EA, Drewry AM, Anderson AL, Casali D, Wallace LA, Kane DS, Tian L, House SL, Fuller BM, Griffey RT, Theodoro DL. Point-of-care Ultrasound-guided Central Venous Catheter Confirmation in Ultrasound Nonexperts. AEM Educ Train 2021; 5:e10530. [PMID: 34124497 PMCID: PMC8173448 DOI: 10.1002/aet2.10530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts. METHODS We performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts. RESULTS Twenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients. CONCLUSION Thirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.
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Affiliation(s)
- Enyo A. Ablordeppey
- From theDepartment of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Anne M. Drewry
- From theDepartment of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
| | - Adam L. Anderson
- theDepartment of Internal MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Diego Casali
- and theDepartment of SurgeryWashington University School of MedicineSt. LouisMOUSA
- and theDepartment of SurgeryDivision of Cardiothoracic SurgeryCedars Sinai Medical CenterLos AngelesCAUSA
| | - Laura A. Wallace
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Deborah S. Kane
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - LinLin Tian
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Stacey L. House
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Brian M. Fuller
- From theDepartment of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Richard T. Griffey
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Daniel L. Theodoro
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
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Unsinger J, Walton AH, Blood T, Tenney DJ, Quigley M, Drewry AM, Hotchkiss RS. Frontline Science: OX40 agonistic antibody reverses immune suppression and improves survival in sepsis. J Leukoc Biol 2021; 109:697-708. [PMID: 33264454 PMCID: PMC7887130 DOI: 10.1002/jlb.5hi0720-043r] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 07/01/2020] [Accepted: 07/26/2020] [Indexed: 12/17/2022] Open
Abstract
A defining feature of protracted sepsis is development of immunosuppression that is thought to be a major driving force in the morbidity and mortality associated with the syndrome. The immunosuppression that occurs in sepsis is characterized by profound apoptosis-induced depletion of CD4 and CD8 T cells and severely impaired T cell function. OX40, a member of the TNF receptor superfamily, is a positive co-stimulatory molecule expressed on activated T cells. When engaged by OX40 ligand, OX40 stimulates T cell proliferation and shifts the cellular immune phenotype toward TH1 with increased production of cytokines that are essential for control of invading pathogens. The purpose of the present study was to determine if administration of agonistic Ab to OX40 could reverse sepsis-induced immunosuppression, restore T cell function, and improve survival in a clinically relevant animal model of sepsis. The present study demonstrates that OX40 agonistic Ab reversed sepsis-induced impairment of T cell function, increased T cell IFN-γ production, increased the number of immune effector cells, and improved survival in the mouse cecal ligation and puncture model of sepsis. Importantly, OX40 agonistic Ab was not only effective in murine sepsis but also improved T effector cell function in PBMCs from patients with sepsis. The present results provide support for the use of immune adjuvants that target T cell depletion and T cell dysfunction in the therapy of sepsis-induced immunosuppression. In addition to the checkpoint inhibitors anti-PD-1 and anti-PD-L1, OX40 agonistic Ab may be a new therapeutic approach to the treatment of this highly lethal disorder.
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Affiliation(s)
- Jacqueline Unsinger
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Andrew H Walton
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Teresa Blood
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel J Tenney
- Bristol Myers Squibb, Leads Discovery & Optimization, Lawrenceville, New Jersey, USA
| | - Michael Quigley
- Bristol Myers Squibb, Oncology Discovery Biology, Redwood City, California, USA
- Current affiliation, Gilead Sciences, Inc., Foster City, California, USA
| | - Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Richard S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Winkler W, Yan Y, Kollef MH, Avidan MS, Fuller BM. The ED-AWARENESS Study: A Prospective, Observational Cohort Study of Awareness With Paralysis in Mechanically Ventilated Patients Admitted From the Emergency Department. Ann Emerg Med 2021; 77:532-544. [PMID: 33485698 DOI: 10.1016/j.annemergmed.2020.10.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Awareness with paralysis is a devastating complication for patients receiving mechanical ventilation and risks long-term psychological morbidity. Data from the emergency department (ED) demonstrate a high rate of longer-acting neuromuscular blocking agent use, delayed analgosedation, and a lack of sedation depth monitoring. These practices are discordant with recommendations for preventing awareness with paralysis. Despite this, awareness with paralysis has not been rigorously studied in the ED population. Our objective is to assess the prevalence of awareness with paralysis in ED patients receiving mechanical ventilation. METHODS This was a single-center, prospective, observational cohort study on 383 mechanically ventilated ED patients. After extubation, we assessed patients for awareness with paralysis by using the modified Brice questionnaire. Three expert reviewers independently adjudicated awareness with paralysis. We report the prevalence of awareness with paralysis (primary outcome); the secondary outcome was perceived threat, a mediator for development of posttraumatic stress disorder. RESULTS The prevalence of awareness with paralysis was 2.6% (10/383). Exposure to rocuronium at any point in the ED was significantly different between patients who experienced awareness with paralysis (70%) versus the rest of the cohort (31.4%) (unadjusted odds ratio 5.1; 95% confidence interval 1.30 to 20.1). Patients experiencing awareness with paralysis had higher mean values on the threat perception scale, denoting a higher degree of perceived threat, compared with patients who did not experience awareness with paralysis (13.4 [SD 7.7] versus 8.5 [SD 6.2]; mean difference 4.9; 95% confidence interval 0.94 to 8.8). CONCLUSION Awareness with paralysis occurs in a significant minority of ED patients who receive mechanical ventilation. Potential associations of awareness with paralysis with ED care and increased perceived threat warrant further evaluation.
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Affiliation(s)
- Ryan D Pappal
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Enyo Ablordeppey
- Department of Emergency Medicine, St. Louis, MO; Department of Anesthesiology, St. Louis, MO
| | - Brian T Wessman
- Department of Emergency Medicine, St. Louis, MO; Department of Anesthesiology, St. Louis, MO
| | | | - Winston Winkler
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Yan Yan
- Public Health Sciences, St. Louis, MO; Clinical Epidemiology Center, VA St. Louis Health Care System, St. Louis, MO
| | | | | | - Brian M Fuller
- Department of Emergency Medicine, St. Louis, MO; Department of Anesthesiology, St. Louis, MO.
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Bonfanti N, Gundert E, Drewry AM, Goff K, Bedimo R, Kulstad E. Core warming of coronavirus disease 2019 (COVID-19) patients undergoing mechanical ventilation-A protocol for a randomized controlled pilot study. PLoS One 2020; 15:e0243190. [PMID: 33259540 PMCID: PMC7707531 DOI: 10.1371/journal.pone.0243190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19), caused by the virus SARS-CoV-2, is spreading rapidly across the globe, with little proven effective therapy. Fever is seen in most cases of COVID-19, at least at the initial stages of illness. Although fever is typically treated (with antipyretics or directly with ice or other mechanical means), increasing data suggest that fever is a protective adaptive response that facilitates recovery from infectious illness. OBJECTIVE To describe a randomized controlled pilot study of core warming patients with COVID-19 undergoing mechanical ventilation. METHODS This prospective single-site randomized controlled pilot study will enroll 20 patients undergoing mechanical ventilation for respiratory failure due to COVID-19. Patients will be randomized 1:1 to standard-of-care or to receive core warming via an esophageal heat exchanger commonly utilized in critical care and surgical patients. The primary outcome is patient viral load measured by lower respiratory tract sample. Secondary outcomes include severity of acute respiratory distress syndrome (as measured by PaO2/FiO2 ratio) 24, 48, and 72 hours after initiation of treatment, hospital and intensive care unit length of stay, duration of mechanical ventilation, and 30-day mortality. RESULTS Resulting data will provide effect size estimates to guide a definitive multi-center randomized clinical trial. ClinicalTrials.gov registration number: NCT04426344. CONCLUSIONS With growing data to support clinical benefits of elevated temperature in infectious illness, this study will provide data to guide further understanding of the role of active temperature management in COVID-19 treatment and provide effect size estimates to power larger studies.
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Affiliation(s)
- Nathaniel Bonfanti
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
- Department of Anesthesia/Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
| | - Emily Gundert
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
- Department of Anesthesia/Critical Care, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
| | - Anne M. Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Kristina Goff
- Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
| | - Roger Bedimo
- Infectious Diseases Section, VA North Texas Health Care System, Dallas, TX, United States of America
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
| | - Erik Kulstad
- Department of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX, United States of America
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12
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Remy KE, Mazer M, Striker DA, Ellebedy AH, Walton AH, Unsinger J, Blood TM, Mudd PA, Yi DJ, Mannion DA, Osborne DF, Martin RS, Anand NJ, Bosanquet JP, Blood J, Drewry AM, Caldwell CC, Turnbull IR, Brakenridge SC, Moldwawer LL, Hotchkiss RS. Severe immunosuppression and not a cytokine storm characterizes COVID-19 infections. JCI Insight 2020; 5:140329. [PMID: 32687484 PMCID: PMC7526441 DOI: 10.1172/jci.insight.140329] [Citation(s) in RCA: 202] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/16/2020] [Indexed: 12/15/2022] Open
Abstract
COVID-19–associated morbidity and mortality have been attributed to a pathologic host response. Two divergent hypotheses have been proposed: hyperinflammatory cytokine storm; and failure of host protective immunity that results in unrestrained viral dissemination and organ injury. A key explanation for the inability to address this controversy has been the lack of diagnostic tools to evaluate immune function in COVID-19 infections. ELISpot, a highly sensitive, functional immunoassay, was employed in 27 patients with COVID-19, 51 patients with sepsis, 18 critically ill nonseptic (CINS) patients, and 27 healthy control volunteers to evaluate adaptive and innate immune status by quantitating T cell IFN-ɣ and monocyte TFN-α production. Circulating T cell subsets were profoundly reduced in COVID-19 patients. Additionally, stimulated blood mononuclear cells produced less than 40%–50% of the IFN-ɣ and TNF-α observed in septic and CINS patients, consistent with markedly impaired immune effector cell function. Approximately 25% of COVID-19 patients had increased IL-6 levels that were not associated with elevations in other canonical proinflammatory cytokines. Collectively, these findings support the hypothesis that COVID-19 suppresses host functional adaptive and innate immunity. Importantly, IL-7 administered ex vivo restored T cell IFN-ɣ production in COVID-19 patients. Thus, ELISpot may functionally characterize host immunity in COVID-19 and inform prospective therapies. ELISpot, a highly sensitive, functional immunoassay, suggests that COVID-19 is immunosuppressive and lacks substantial cytokine storm.
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Affiliation(s)
- Kenneth E Remy
- Department of Pediatrics.,Department of Internal Medicine, and.,Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Monty Mazer
- Department of Pediatrics.,Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - David A Striker
- Department of Critical Care, Missouri Baptist Medical Center, St. Louis, USA
| | | | - Andrew H Walton
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jacqueline Unsinger
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Teresa M Blood
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Philip A Mudd
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Daniel A Mannion
- Department of Pediatrics.,Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Dale F Osborne
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - R Scott Martin
- Department of Critical Care, Missouri Baptist Medical Center, St. Louis, USA
| | - Nitin J Anand
- Department of Critical Care, Missouri Baptist Medical Center, St. Louis, USA
| | - James P Bosanquet
- Department of Critical Care, Missouri Baptist Medical Center, St. Louis, USA
| | - Jane Blood
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Charles C Caldwell
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Isaiah R Turnbull
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Scott C Brakenridge
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Lyle L Moldwawer
- Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Richard S Hotchkiss
- Department of Internal Medicine, and.,Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.,Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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13
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Drewry AM, Hotchkiss R, Kulstad E. Response to "Body temperature correlates with mortality in COVID-19 patients". Crit Care 2020; 24:460. [PMID: 32709253 PMCID: PMC7380658 DOI: 10.1186/s13054-020-03186-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/16/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Anne M Drewry
- Surgical Intensive Care Unit, Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8054, St. Louis, MO, 63110, USA
| | - Richard Hotchkiss
- Anesthesiology, Medicine, Surgery, and Developmental Biology, Washington University School of Medicine, 660 S. Euclid Ave., Campus, Box 8054, St. Louis, MO, 63110, USA
| | - Erik Kulstad
- Department of Emergency Medicine, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
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Affiliation(s)
- Anne M. Drewry
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8054, St. Louis, MO 63110 USA
| | - Richard Hotchkiss
- Anesthesiology, Medicine, Surgery, and Developmental Biology, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8054, St. Louis, MO 63110 USA
| | - Erik Kulstad
- Department of Emergency Medicine, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
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15
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Pappal RD, Roberts BW, Mohr NM, Ablordeppey E, Wessman BT, Drewry AM, Yan Y, Kollef MH, Avidan MS, Fuller BM. Protocol for a prospective, observational cohort study of awareness in mechanically ventilated patients admitted from the emergency department: the ED-AWARENESS study. BMJ Open 2019; 9:e033379. [PMID: 31594905 PMCID: PMC6797343 DOI: 10.1136/bmjopen-2019-033379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Awareness with paralysis is a complication with potentially devastating psychological consequences for mechanically ventilated patients. While rigorous investigation into awareness has occurred for operating room patients, little attention has been paid outside of this domain. Mechanically ventilated patients in the emergency department (ED) have been historically managed in a way that predisposes them to awareness events: high incidence of neuromuscular blockade use, underdosing of analgesia and sedation, delayed administration of analgesia and sedation after intubation, and a lack of monitoring of sedation targets and depth. These practice patterns are discordant to recommendations for reducing the incidence of awareness, suggesting there is significant rationale to examine awareness in the ED population. METHODS AND ANALYSIS This is a single centre, prospective cohort study examining the incidence of awareness in mechanically ventilated ED patients. A cohort of 383 mechanically ventilated ED patients will be included. The primary outcome is awareness with paralysis. Qualitative reports of all awareness events will be provided. Recognising the potential problem with conventional multivariable analysis arising from a small number of events (expected less than 10-phenomenon of separation), Firth penalised method, exact logistic regression model or penalised maximum likelihood estimation shrinkage (Ridge, LASSO) will be used to assess for predictors of awareness. ETHICS AND DISSEMINATION Approval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.
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Affiliation(s)
- Ryan D Pappal
- Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brian W Roberts
- Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Nicholas M Mohr
- Emergency Medicine and Anesthesiology, Roy J. and Lucille A. Carver College of Medicine University of Iowa, Iowa City, Iowa, USA
| | - Enyo Ablordeppey
- Anesthesiology and Emergency Medicine, Washington University, Saint Louis, Missouri, USA
| | - Brian T Wessman
- Anesthesiology and Emergency Medicine, Washington University, Saint Louis, Missouri, USA
| | - Anne M Drewry
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Yan Yan
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, Missouri, USA
- Public Health Sciences, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Marin H Kollef
- Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Michael Simon Avidan
- Anesthesiology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Brian M Fuller
- Anesthesiology and Emergency Medicine, Washington University, Saint Louis, Missouri, USA
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16
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Roberts BW, Mohr NM, Ablordeppey E, Drewry AM, Ferguson IT, Trzeciak S, Kollef MH, Fuller BM. Association Between Partial Pressure of Arterial Carbon Dioxide and Survival to Hospital Discharge Among Patients Diagnosed With Sepsis in the Emergency Department. Crit Care Med 2018; 46:e213-e220. [PMID: 29261567 PMCID: PMC5825256 DOI: 10.1097/ccm.0000000000002918] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of this study was to test the association between the partial pressure of arterial carbon dioxide and survival to hospital discharge among mechanically ventilated patients diagnosed with sepsis in the emergency department. DESIGN Retrospective cohort study of a single center trial registry. SETTING Academic medical center. PATIENTS Mechanically ventilated emergency department patients. INCLUSION CRITERIA age 18 years and older, diagnosed with sepsis in the emergency department, and mechanical ventilation initiated in the emergency department. INTERVENTIONS Arterial blood gases obtained after initiation of mechanical ventilation were analyzed. The primary outcome was survival to hospital discharge. We tested the association between partial pressure of arterial carbon dioxide and survival using multivariable logistic regression adjusting for potential confounders. Sensitivity analyses, including propensity score matching were also performed. MEASUREMENTS AND MAIN RESULTS Six hundred subjects were included, and 429 (72%) survived to hospital discharge. The median (interquartile range) partial pressure of arterial carbon dioxide was 42 (34-53) mm Hg for the entire cohort and 44 (35-57) and 39 (31-45) mm Hg among survivors and nonsurvivors, respectively (p < 0.0001 Wilcox rank-sum test). On multivariable analysis, a 1 mm Hg rise in partial pressure of arterial carbon dioxide was associated with a 3% increase in odds of survival (adjusted odds ratio, 1.03; 95% CI, 1.01-1.04) after adjusting for tidal volume and other potential confounders. These results remained significant on all sensitivity analyses. CONCLUSION In this sample of mechanically ventilated sepsis patients, we found an association between increasing levels of partial pressure of arterial carbon dioxide and survival to hospital discharge. These findings justify future studies to determine the optimal target partial pressure of arterial carbon dioxide range for mechanically ventilated sepsis patients.
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Affiliation(s)
- Brian W. Roberts
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Nicholas M. Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Enyo Ablordeppey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Anne M. Drewry
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ian T. Ferguson
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Stephen Trzeciak
- The Department of Emergency Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
- The Department of Medicine, Division of Critical Care Medicine, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Marin H. Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Brian M. Fuller
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Department of Anesthesiology, Division of Critical Care, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Page DB, Drewry AM, Ablordeppey E, Mohr NM, Kollef MH, Fuller BM. Thirty-day hospital readmissions among mechanically ventilated emergency department patients. Emerg Med J 2018; 35:252-256. [PMID: 29305381 DOI: 10.1136/emermed-2017-206651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 10/15/2017] [Accepted: 11/30/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Unplanned 30-day readmissions have a negative impact on patients and healthcare systems. Mechanically ventilated ED patients are at high risk for complications, but factors associated with readmission are unknown. OBJECTIVE (1) Determine the rate of 30-day hospital readmission for ED patients receiving mechanical ventilation. (2) Identify associations between ED-based risk factors and readmission. DESIGN Retrospective cohort study. SETTING Tertiary-care, academic medical centre. PATIENTS Adult ED patients receiving mechanical ventilation. MEASUREMENTS Baseline demographics, comorbid conditions, illness severity and treatment variables were collected, as were clinical outcomes occurring during the index hospitalisation. The primary outcome was 30-day hospital readmission rate. Multivariable logistic regression was used to evaluate factors associated with the primary outcome. RESULTS A total of 1262 patients were studied. The primary outcome occurred in 287 (22.7%) patients. There was no association between care in the ED and readmission. During the index hospitalisation, readmitted patients had shorter ventilator, hospital and intensive care unit duration (P<0.05 for all). The primary outcome was associated with African-American race (adjusted OR 1.34 (95% CI 1.02 to 1.78)), chronic obstructive pulmonary disease (adjusted OR 1.52 (95% CI 1.12 to 2.06)), diabetes mellitus (adjusted OR 1.34 (95% CI 1.02 to 1.78)) and higher illness severity (adjusted OR 1.03 (95% CI 1.01 to 1.05)). CONCLUSIONS Almost one in four mechanically ventilated ED patients are readmitted within 30 days, and readmission is associated with patient-level and institutional-level factors. Strategies must be developed to identify, treat and coordinate care for the most at-risk patients.
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Affiliation(s)
- David B Page
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Enyo Ablordeppey
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine, St Louis, Missouri, USA
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J and Lucille A Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington University School of Medicine, St Louis, Missouri, USA
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18
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Fuller BM, Mohr NM, Drewry AM, Ferguson IT, Trzeciak S, Kollef MH, Roberts BW. Partial pressure of arterial carbon dioxide and survival to hospital discharge among patients requiring acute mechanical ventilation: A cohort study. J Crit Care 2017; 41:29-35. [PMID: 28472700 PMCID: PMC5633513 DOI: 10.1016/j.jcrc.2017.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/18/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To describe the prevalence of hypocapnia and hypercapnia during the earliest period of mechanical ventilation, and determine the association between PaCO2 and mortality. MATERIALS AND METHODS A cohort study using an emergency department registry of mechanically ventilated patients. PaCO2 was categorized: hypocapnia (<35mmHg), normocapnia (35-45mmHg), and hypercapnia (>45mmHg). The primary outcome was survival to hospital discharge. RESULTS A total of 1,491 patients were included. Hypocapnia occurred in 375 (25%) patients and hypercapnia in 569 (38%). Hypercapnia (85%) had higher survival rate compared to normocapnia (74%) and hypocapnia (66%), P<0.001. PaCO2 was an independent predictor of survival to hospital discharge [hypocapnia (aOR 0.65 (95% confidence interval [CI] 0.48-0.89), normocapnia (reference category), hypercapnia (aOR 1.83 (95% CI 1.32-2.54)]. Over ascending ranges of PaCO2, there was a linear trend of increasing survival up to a PaCO2 range of 66-75mmHg, which had the strongest survival association, aOR 3.18 (95% CI 1.35-7.50). CONCLUSIONS Hypocapnia and hypercapnia occurred frequently after initiation of mechanical ventilation. Higher PaCO2 levels were associated with increased survival. These data provide rationale for a trial examining the optimal PaCO2 in the critically ill.
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Affiliation(s)
- Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, United States.
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242, United States.
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, United States.
| | - Ian T Ferguson
- School of Medicine and Medical Science, University College Dublin, Dublin 4, Ireland.
| | - Stephen Trzeciak
- Departments of Medicine and Emergency Medicine, Division of Critical Care Medicine, Cooper University Hospital, One Cooper Plaza, K152, Camden, NJ 08103, United States.
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, United States.
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, One Cooper Plaza, K152, Camden, NJ 08103, United States.
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Stephens RJ, Ablordeppey E, Drewry AM, Palmer C, Wessman BT, Mohr NM, Roberts BW, Liang SY, Kollef MH, Fuller BM. Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED: A Cohort Study. Chest 2017. [PMID: 28645462 DOI: 10.1016/j.chest.2017.05.041] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Analgesia and sedation are cornerstone therapies for mechanically ventilated patients. Despite data showing that early deep sedation in the ICU influences outcome, this has not been investigated in the ED. Therefore, ED-based sedation practices, and their influence on outcome, remain incompletely defined. This study's objectives were to describe ED sedation practices in mechanically ventilated patients and to test the hypothesis that ED sedation depth is associated with worse outcomes. METHODS This was a cohort study of a prospectively compiled ED registry of adult mechanically ventilated patients at a single academic medical center. Hospital mortality was the primary outcome and hospital-, ICU-, and ventilator-free days were secondary outcomes. A backward stepwise multivariable logistic regression model evaluated the primary outcome as a function of ED sedation depth. Sedation depth was assessed with the Richmond Agitation-Sedation Scale (RASS). RESULTS Four hundred fourteen patients were studied. In the ED, 354 patients (85.5%) received fentanyl, 254 (61.3%) received midazolam, and 194 (46.9%) received propofol. Deep sedation was observed in 244 patients (64.0%). After adjusting for confounders, a deeper ED RASS was associated with mortality (adjusted OR, 0.77; 95% CI, 0.63-0.94). CONCLUSIONS Early deep sedation is common in mechanically ventilated ED patients and is associated with worse mortality. These data suggest that ED-based sedation is a modifiable variable that could be targeted to improve outcome.
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Affiliation(s)
- Robert J Stephens
- Washington University School of Medicine in St. Louis, St. Louis, MO.
| | - Enyo Ablordeppey
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington School of Medicine in St. Louis, St. Louis, MO
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington School of Medicine in St. Louis, St. Louis, MO
| | - Christopher Palmer
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington School of Medicine in St. Louis, St. Louis, MO
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
| | - Stephen Y Liang
- Departments of Medicine and Emergency Medicine, Division of Infectious Diseases, Washington School of Medicine in St. Louis, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington School of Medicine in St. Louis, St. Louis, MO
| | - Brian M Fuller
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Washington School of Medicine in St. Louis, St. Louis, MO
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Drewry AM, Ablordeppey EA, Murray ET, Stoll CRT, Izadi SR, Dalton CM, Hardi AC, Fowler SA, Fuller BM, Colditz GA. Antipyretic Therapy in Critically Ill Septic Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 45:806-813. [PMID: 28221185 PMCID: PMC5389594 DOI: 10.1097/ccm.0000000000002285] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This meta-analysis aimed to examine the impact of antipyretic therapy on mortality in critically ill septic adults. DATA SOURCES Literature searches were implemented in Ovid Medline, Embase, Scopus, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, and ClinicalTrials.gov through February 2016. STUDY SELECTION Inclusion criteria were observational or randomized studies of septic patients, evaluation of antipyretic treatment, mortality reported, and English-language version available. Studies were excluded if they enrolled pediatric patients, patients with neurologic injury, or healthy volunteers. Criteria were applied by two independent reviewers. DATA EXTRACTION Two reviewers independently extracted data and evaluated methodologic quality. Outcomes included mortality, frequency of shock reversal, acquisition of nosocomial infections, and changes in body temperature, heart rate, and minute ventilation. Randomized and observational studies were analyzed separately. DATA SYNTHESIS Eight randomized studies (1,507 patients) and eight observational studies (17,432 patients) were analyzed. Antipyretic therapy did not reduce 28-day/hospital mortality in the randomized studies (relative risk, 0.93; 95% CI, 0.77-1.13; I = 0.0%) or observational studies (odds ratio, 0.90; 95% CI, 0.54-1.51; I = 76.1%). Shock reversal (relative risk, 1.13; 95% CI, 0.68-1.90; I = 51.6%) and acquisition of nosocomial infections (relative risk, 1.13; 95% CI, 0.61-2.09; I = 61.0%) were also unchanged. Antipyretic therapy decreased body temperature (mean difference, -0.38°C; 95% CI, -0.63 to -0.13; I = 84.0%), but not heart rate or minute ventilation. CONCLUSIONS Antipyretic treatment does not significantly improve 28-day/hospital mortality in adult patients with sepsis.
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Affiliation(s)
- Anne M Drewry
- 1Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO. 2Departments of Emergency Medicine and Anesthesiology, Washington University School of Medicine, St. Louis, MO. 3University of Missouri-Columbia School of Medicine, Columbia, MO. 4Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO. 5Bernard Becker Medical Library, Washington University School of Medicine, St. Louis, MO
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Fuller BM, Ferguson IT, Mohr NM, Drewry AM, Palmer C, Wessman BT, Ablordeppey E, Keeperman J, Stephens RJ, Briscoe CC, Kolomiets AA, Hotchkiss RS, Kollef MH. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med 2017; 70:406-418.e4. [PMID: 28259481 DOI: 10.1016/j.annemergmed.2017.01.013] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE We evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications. METHODS This was a quasi-experimental, before-after study that consisted of a preintervention period, a run-in period of approximately 6 months, and a prospective intervention period. The intervention was a multifaceted ED-based mechanical ventilator protocol targeting lung-protective tidal volume, appropriate setting of positive end-expiratory pressure, rapid oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator-associated conditions. RESULTS A total of 1,192 patients in the preintervention group and 513 patients in the intervention group were included. Lung-protective ventilation increased by 48.4% in the intervention group. In the propensity score-matched analysis (n=490 in each group), the primary outcome occurred in 71 patients (14.5%) in the preintervention group compared with 36 patients (7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence interval [CI] 0.31 to 0.71). There was an increase in ventilator-free days (mean difference 3.7; 95% CI 2.3 to 5.1), ICU-free days (mean difference 2.4; 95% CI 1.0 to 3.7), and hospital-free days (mean difference 2.4; 95% CI 1.2 to 3.6) associated with the intervention. The mortality rate was 34.1% in the preintervention group and 19.6% in the intervention group (adjusted odds ratio 0.47; 95% CI 0.35 to 0.63). CONCLUSION Implementing a mechanical ventilator protocol in the ED is feasible and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.
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Affiliation(s)
- Brian M Fuller
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.
| | - Ian T Ferguson
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher Palmer
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Enyo Ablordeppey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jacob Keeperman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Robert J Stephens
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Angelina A Kolomiets
- School of Public Health and Social Justice, Saint Louis University, St. Louis, MO
| | - Richard S Hotchkiss
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
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Drewry AM, Ablordeppey EA, Murray ET, Beiter ER, Walton AH, Hall MW, Hotchkiss RS. Comparison of monocyte human leukocyte antigen-DR expression and stimulated tumor necrosis factor alpha production as outcome predictors in severe sepsis: a prospective observational study. Crit Care 2016; 20:334. [PMID: 27760554 PMCID: PMC5072304 DOI: 10.1186/s13054-016-1505-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Identifying patients in the immunosuppressive phase of sepsis is essential for development of immunomodulatory therapies. Little data exists comparing the ability of the two most well-studied markers of sepsis-induced immunosuppression, human leukocyte antigen (HLA)-DR expression and lipopolysaccharide (LPS)-induced tumor necrosis factor alpha (TNF-ɑ) production, to predict mortality and morbidity. The purpose of this study was to compare HLA-DR expression and LPS-induced TNF-ɑ production as predictors of 28-day mortality and acquisition of secondary infections in adult septic patients. METHODS A single-center, prospective observational study of 83 adult septic patients admitted to a medical or surgical intensive care unit. Blood samples were collected at three time points during the septic course (days 1-2, days 3-4, and days 6-8 after sepsis diagnosis) and assayed for HLA-DR expression and LPS-induced TNF-ɑ production. A repeated measures mixed model analysis was used to compare values of these immunological markers among survivors and non-survivors and among those who did and did not develop a secondary infection. RESULTS Twenty-five patients (30.1 %) died within 28 days of sepsis diagnosis. HLA-DR expression was significantly lower in non-survivors as compared to survivors on days 3-4 (p = 0.04) and days 6-8 (p = 0.002). The change in HLA-DR from days 1-2 to days 6-8 was also lower in non-survivors (p = 0.04). Median HLA-DR expression decreased from days 1-2 to days 3-4 in patients who developed secondary infections while it increased in those without secondary infections (p = 0.054). TNF-ɑ production did not differ between survivors and non-survivors or between patients who did and did not develop a secondary infection. CONCLUSIONS Monocyte HLA-DR expression may be a more accurate predictor of mortality and acquisition of secondary infections than LPS-stimulated TNF-ɑ production in adult medical and surgical critically ill patients.
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Affiliation(s)
- Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO, USA.
| | - Enyo A Ablordeppey
- Departments of Anesthesiology and Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ellen T Murray
- University of Missouri-Columbia School of Medicine, Columbia, MO, USA
| | - Evan R Beiter
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO, USA
| | - Andrew H Walton
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO, USA
| | - Mark W Hall
- Department of Pediatrics, Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Richard S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid, St. Louis, MO, USA
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Patera AC, Drewry AM, Chang K, Beiter ER, Osborne D, Hotchkiss RS. Frontline Science: Defects in immune function in patients with sepsis are associated with PD-1 or PD-L1 expression and can be restored by antibodies targeting PD-1 or PD-L1. J Leukoc Biol 2016; 100:1239-1254. [PMID: 27671246 DOI: 10.1189/jlb.4hi0616-255r] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/01/2016] [Accepted: 08/26/2016] [Indexed: 12/20/2022] Open
Abstract
Sepsis is a heterogeneous syndrome comprising a highly diverse and dynamic mixture of hyperinflammatory and compensatory anti-inflammatory immune responses. This immune phenotypic diversity highlights the importance of proper patient selection for treatment with the immunomodulatory drugs that are entering clinical trials. To better understand the serial changes in immunity of critically ill patients and to evaluate the potential efficacy of blocking key inhibitory pathways in sepsis, we undertook a broad phenotypic and functional analysis of innate and acquired immunity in the same aliquot of blood from septic, critically ill nonseptic, and healthy donors. We also tested the ability of blocking the checkpoint inhibitors programmed death receptor-1 (PD-1) and its ligand (PD-L1) to restore the function of innate and acquired immune cells. Neutrophil and monocyte function (phagocytosis, CD163, cytokine expression) were progressively diminished as sepsis persisted. An increasing frequency in PD-L1+-suppressor phenotype neutrophils [low-density neutrophils (LDNs)] was also noted. PD-L1+ LDNs and defective neutrophil function correlated with disease severity, consistent with the potential importance of suppressive neutrophil populations in sepsis. Reduced neutrophil and monocyte function correlated both with their own PD-L1 expression and with PD-1 expression on CD8+ T cells and NK cells. Conversely, reduced CD8+ T cell and NK cell functions (IFN-γ production, granzyme B, and CD107a expression) correlated with elevated PD-L1+ LDNs. Importantly, addition of antibodies against PD-1 or PD-L1 restored function in neutrophil, monocyte, T cells, and NK cells, underlining the impact of the PD-1:PD-L1 axis in sepsis-immune suppression and the ability to treat multiple deficits with a single immunomodulatory agent.
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Affiliation(s)
- Andriani C Patera
- Infectious Disease and Vaccines Department, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Katherine Chang
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Evan R Beiter
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dale Osborne
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Richard S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Spec A, Shindo Y, Burnham CAD, Wilson S, Ablordeppey EA, Beiter ER, Chang K, Drewry AM, Hotchkiss RS. T cells from patients with Candida sepsis display a suppressive immunophenotype. Crit Care 2016; 20:15. [PMID: 26786705 PMCID: PMC4719210 DOI: 10.1186/s13054-016-1182-z] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 01/05/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite appropriate therapy, Candida bloodstream infections are associated with a mortality rate of approximately 40%. In animal models, impaired immunity due to T cell exhaustion has been implicated in fungal sepsis mortality. The purpose of this study was to determine potential mechanisms of fungal-induced immunosuppression via immunophenotyping of circulating T lymphocytes from patients with microbiologically documented Candida bloodstream infections. METHODS Patients with blood cultures positive for any Candida species were studied. Non-septic critically ill patients with no evidence of bacterial or fungal infection were controls. T cells were analyzed via flow cytometry for cellular activation and for expression of positive and negative co-stimulatory molecules. Both the percentages of cells expressing particular immunophenotypic markers as well as the geometric mean fluorescence intensity (GMFI), a measure of expression of the number of receptors or ligands per cell, were quantitated. RESULTS Twenty-seven patients with Candida bloodstream infections and 16 control patients were studied. Compared to control patients, CD8 T cells from patients with Candidemia had evidence of cellular activation as indicated by increased CD69 expression while CD4 T cells had decreased expression of the major positive co-stimulatory molecule CD28. CD4 and CD8 T cells from patients with Candidemia expressed markers typical of T cell exhaustion as indicated by either increased percentages of or increased MFI for programmed cell death 1 (PD-1) or its ligand (PD-L1). CONCLUSIONS Circulating immune effector cells from patients with Candidemia display an immunophenotype consistent with immunosuppression as evidenced by T cell exhaustion and concomitant downregulation of positive co-stimulatory molecules. These findings may help explain why patients with fungal sepsis have a high mortality despite appropriate antifungal therapy. Development of immunoadjuvants that reverse T cell exhaustion and boost host immunity may offer one way to improve outcome in this highly lethal disorder.
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Affiliation(s)
- Andrej Spec
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Yuichiro Shindo
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Strother Wilson
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Enyo A Ablordeppey
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Evan R Beiter
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Katherine Chang
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Richard S Hotchkiss
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA. .,Department of Anesthesiology, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA. .,Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA.
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Skrupky LP, Drewry AM, Wessman B, Field RR, Fagley RE, Varghese L, Lieu A, Olatunde J, Micek ST, Kollef MH, Boyle WA. Clinical effectiveness of a sedation protocol minimizing benzodiazepine infusions and favoring early dexmedetomidine: a before-after study. Crit Care 2015; 19:136. [PMID: 25887495 PMCID: PMC4403893 DOI: 10.1186/s13054-015-0874-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/11/2015] [Indexed: 01/16/2023]
Abstract
Introduction Randomized controlled trials suggest clinical outcomes may be improved with dexmedetomidine as compared with benzodiazepines; however, further study and validation are needed. The objective of this study was to determine the clinical effectiveness of a sedation protocol minimizing benzodiazepine use in favor of early dexmedetomidine. Methods We conducted a before-after study including adult surgical and medical intensive care unit (ICU) patients requiring mechanical ventilation and continuous sedation for at least 24 hours. The before phase included consecutive patients admitted between 1 April 2011 and 31 August 31 2011. Subsequently, the protocol was modified to minimize use of benzodiazepines in favor of early dexmedetomidine through a multidisciplinary approach, and staff education was provided. The after phase included consecutive eligible patients between 1 May 2012 and 31 October 2012. Results A total of 199 patients were included, with 97 patients in the before phase and 102 in the after phase. Baseline characteristics were well balanced between groups. Use of midazolam as initial sedation (58% versus 27%, P <0.0001) or at any point during the ICU stay (76% versus 48%, P <0.0001) was significantly reduced in the after phase. Dexmedetomidine use as initial sedation (2% versus 39%, P <0.0001) or at any point during the ICU stay (39% versus 82%, P <0.0001) significantly increased. Both the prevalence (81% versus 93%, P =0.013) and median percentage of days with delirium (55% (interquartile range (IQR), 18 to 83) versus 71% (IQR, 45 to 100), P =0.001) were increased in the after phase. The median duration of mechanical ventilation was significantly reduced in the after phase (110 (IQR, 59 to 192) hours versus 74.5 (IQR, 42 to 148) hours, P =0.029), and significantly fewer patients required tracheostomy (20% versus 9%, P =0.040). The median ICU length of stay was 8 (IQR, 4 to 12) days in the before phase and 6 (IQR, 3 to 11) days in the after phase (P =0.252). Conclusions Implementing a sedation protocol that targeted light sedation and reduced benzodiazepine use led to significant improvements in the duration of mechanical ventilation and the requirement for tracheostomy, despite increases in the prevalence and duration of ICU delirium.
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Affiliation(s)
- Lee P Skrupky
- Department of Pharmacy, Aurora Baycare Medical Center, 2845 Greenbrier Road, PO Box 8900, Green Bay, WI, 54311, USA.
| | - Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, St Louis, MO, 63110, USA.
| | - Brian Wessman
- Department of Anesthesiology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, St Louis, MO, 63110, USA. .,Department of Emergency Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8072, St Louis, MO, 63110, USA.
| | - R Ryan Field
- Department of Anesthesiology & Perioperative Care, UC Irvine Medical Center, 333 City Boulevard West, Suite 2050, Orange, CA, 92868, USA.
| | - Richard E Fagley
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue, Mailstop B2-AN, PO Box 900, Seattle, WA, 98101, USA.
| | - Linda Varghese
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792, USA.
| | - Angela Lieu
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 11 Country Squire Lane, Holmdel, NJ, 07733, USA.
| | | | - Scott T Micek
- St Louis College of Pharmacy, 4588 Parkview Place, St. Louis, MO, 63110, USA.
| | - Marin H Kollef
- Department of Pulmonary and Critical Care, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, St. Louis, MO, 63110, USA.
| | - Walter A Boyle
- Department of Anesthesiology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, St Louis, MO, 63110, USA.
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Affiliation(s)
- Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO.
| | - Richard S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO; Department of Surgery, Washington University School of Medicine, St. Louis, MO; Department of Medicine, Washington University School of Medicine, St. Louis, MO
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Affiliation(s)
- Anne M Drewry
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO.
| | - Richard S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO; Department of Surgery, Washington University School of Medicine, St. Louis, MO; Department of Medicine, Washington University School of Medicine, St. Louis, MO
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Drewry AM, Fuller BM, Bailey TC, Hotchkiss RS. Body temperature patterns as a predictor of hospital-acquired sepsis in afebrile adult intensive care unit patients: a case-control study. Crit Care 2013; 17:R200. [PMID: 24028682 PMCID: PMC3906745 DOI: 10.1186/cc12894] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 09/12/2013] [Indexed: 12/16/2022]
Abstract
Introduction Early treatment of sepsis improves survival, but early diagnosis of hospital-acquired sepsis, especially in critically ill patients, is challenging. Evidence suggests that subtle changes in body temperature patterns may be an early indicator of sepsis, but data is limited. The aim of this study was to examine whether abnormal body temperature patterns, as identified by visual examination, could predict the subsequent diagnosis of sepsis in afebrile critically ill patients. Methods Retrospective case-control study of 32 septic and 29 non-septic patients in an adult medical and surgical ICU. Temperature curves for the period starting 72 hours and ending 8 hours prior to the clinical suspicion of sepsis (for septic patients) and for the 72-hour period prior to discharge from the ICU (for non-septic patients) were rated as normal or abnormal by seven blinded physicians. Multivariable logistic regression was used to compare groups in regard to maximum temperature, minimum temperature, greatest change in temperature in any 24-hour period, and whether the majority of evaluators rated the curve to be abnormal. Results Baseline characteristics of the groups were similar except the septic group had more trauma patients (31.3% vs. 6.9%, p = .02) and more patients requiring mechanical ventilation (75.0% vs. 41.4%, p = .008). Multivariable logistic regression to control for baseline differences demonstrated that septic patients had significantly larger temperature deviations in any 24-hour period compared to control patients (1.5°C vs. 1.1°C, p = .02). An abnormal temperature pattern was noted by a majority of the evaluators in 22 (68.8%) septic patients and 7 (24.1%) control patients (adjusted OR 4.43, p = .017). This resulted in a sensitivity of 0.69 (95% CI [confidence interval] 0.50, 0.83) and specificity of 0.76 (95% CI 0.56, 0.89) of abnormal temperature curves to predict sepsis. The median time from the temperature plot to the first culture was 9.40 hours (IQR [inter-quartile range] 8.00, 18.20) and to the first dose of antibiotics was 16.90 hours (IQR 8.35, 34.20). Conclusions Abnormal body temperature curves were predictive of the diagnosis of sepsis in afebrile critically ill patients. Analysis of temperature patterns, rather than absolute values, may facilitate decreased time to antimicrobial therapy.
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Fuller BM, Mohr NM, Drewry AM, Carpenter CR. Lower tidal volume at initiation of mechanical ventilation may reduce progression to acute respiratory distress syndrome: a systematic review. Crit Care 2013; 17:R11. [PMID: 23331507 PMCID: PMC3983656 DOI: 10.1186/cc11936] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/18/2013] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The most appropriate tidal volume in patients without acute respiratory distress syndrome (ARDS) is controversial and has not been rigorously examined. Our objective was to determine whether a mechanical ventilation strategy using lower tidal volume is associated with a decreased incidence of progression to ARDS when compared with a higher tidal volume strategy. METHODS A systematic search of MEDLINE, EMBASE, CINAHL, the Cochrane Library, conference proceedings, and clinical trial registration was performed with a comprehensive strategy. Studies providing information on mechanically ventilated patients without ARDS at the time of initiation of mechanical ventilation, and in which tidal volume was independently studied as a predictor variable for outcome, were included. The primary outcome was progression to ARDS. RESULTS The search yielded 1,704 studies, of which 13 were included in the final analysis. One randomized controlled trial was found; the remaining 12 studies were observational. The patient cohorts were significantly heterogeneous in composition and baseline risk for developing ARDS; therefore, a meta-analysis of the data was not performed. The majority of the studies (n = 8) showed a decrease in progression to ARDS with a lower tidal volume strategy. ARDS developed early in the course of illness (5 hours to 3.7 days). The development of ARDS was associated with increased mortality, lengths of stay, mechanical ventilation duration, and nonpulmonary organ failure. CONCLUSIONS In mechanically ventilated patients without ARDS at the time of endotracheal intubation, the majority of data favors lower tidal volume to reduce progression to ARDS. However, due to significant heterogeneity in the data, no definitive recommendations can be made. Further randomized controlled trials examining the role of lower tidal volumes in patients without ARDS, controlling for ARDS risk, are needed.
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Affiliation(s)
- Brian M Fuller
- Department of Anesthesiology, Division of Critical Care, Division of Emergency Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, St. Louis, MO, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, Department of Anesthesia, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 375 Newton Road, Iowa City, IA, USA
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, St. Louis, MO, USA
| | - Christopher R Carpenter
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, St. Louis, MO, USA
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Wagner TH, Drewry AM, Macmillan S, Dunne WM, Chang KC, Karl IE, Hotchkiss RS, Cobb JP. Surviving sepsis: bcl-2 overexpression modulates splenocyte transcriptional responses in vivo. Am J Physiol Regul Integr Comp Physiol 2007; 292:R1751-9. [PMID: 17234957 DOI: 10.1152/ajpregu.00656.2006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We hypothesized that spleen microarray gene expression profiles analyzed with contemporary pathway analysis software would provide molecular pathways of interest and target genes that might help explain the effect of bcl-2 on improving survival during sepsis. Two mouse models of sepsis, cecal ligation and puncture and tracheal instillation of Pseudomonas aeruginosa, were tested in both wild-type mice and mice that overexpress bcl-2. Whole spleens were obtained 6 h after septic injury. DNA microarray transcriptional profiles were obtained using the Affymetrix 430A GeneChip, containing 22,690 elements. Ingenuity Pathway Analysis software was used to construct hypothetical transcriptional networks that changed in response to sepsis and expression of the bcl-2 transgene. A conservative approach was used wherein only changes induced by both abdominal and pulmonary sepsis were studied. At 6 h, sepsis induced alterations in the abundance of hundreds of spleen genes, including a number of proinflammatory mediators (e.g., interleukin-6). These sepsis-induced alterations were blocked by expression of the bcl-2 transgene. Network analysis implicated a number of bcl-2-related apoptosis genes, including bcl2L11 (bim), bcl-2L2 (bcl-w), bmf, and mcl-1. Sepsis in bcl-2 transgenic animals resulted in alteration of RNA abundance for only a single gene, ceacam1. These findings are consistent with sepsis-induced alterations in the balance of pro- and anti-apoptotic transcriptional networks. In addition, our data suggest that the ability of bcl-2 overexpression to improve survival in sepsis in this model is related in part to prevention of sepsis-induced alterations in spleen transcriptional responses.
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Affiliation(s)
- Tracey H Wagner
- Department of Anesthesiology, School of Medicine, Washington University in St. Louis, St. Louis, MO 63110, USA
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Tinsley KW, Grayson MH, Swanson PE, Drewry AM, Chang KC, Karl IE, Hotchkiss RS. Sepsis induces apoptosis and profound depletion of splenic interdigitating and follicular dendritic cells. J Immunol 2003; 171:909-14. [PMID: 12847261 DOI: 10.4049/jimmunol.171.2.909] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Dendritic cells are a phenotypically diverse group of APC that have unique capabilities to regulate the activity and survival of B and T cells. Although proper function of dendritic cells is essential to host control of invading pathogens, few studies have examined the impact of sepsis on dendritic cells. The purpose of this study was to determine the effect of sepsis on splenic interdigitating dendritic cells (IDCs) and follicular dendritic cells (FDCs) using a clinically relevant animal model. Immunohistochemical staining for FDCs showed that sepsis induced an initial marked expansion in FDCs that peaked at 36 h after onset. The FDCs expanded to fill the entire lymphoid zone otherwise occupied by B cells. Between 36 and 48 h after sepsis, there was a profound caspase 3 mediated apoptosis induced depletion of FDCs such that only a small contingent of cells remained. In contrast to the initial increase in FDCs, IDC numbers were decreased to approximately 50% of control by 12 h after onset of sepsis. IDC death occurred by caspase 3-mediated apoptosis. Such profound apoptosis induced loss of FDCs and IDCs may significantly compromise B and T cell function and impair the ability of the host to survive sepsis.
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Affiliation(s)
- Kevin W Tinsley
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Hotchkiss RS, Tinsley KW, Hui JJ, Chang KC, Swanson PE, Drewry AM, Buchman TG, Karl IE. p53-dependent and -independent pathways of apoptotic cell death in sepsis. J Immunol 2000; 164:3675-80. [PMID: 10725725 DOI: 10.4049/jimmunol.164.7.3675] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Sepsis induces extensive apoptosis of lymphocytes, which may be responsible for the profound immune suppression of the disorder. Two potential pathways of sepsis-induced lymphocyte apoptosis, Fas and p53, were investigated. Lymphocyte apoptosis was evaluated 20-22 h after sepsis by annexin V or DNA nick-end labeling. Fas receptor-deficient mice had no protection against sepsis-induced apoptosis in thymocytes or splenocytes. p53 knockout mice (p53-/-) had complete protection against thymocyte apoptosis but, surprisingly, had no protection in splenocytes. p53-/- mice had no improvement in sepsis survival compared with appropriately matched control mice with sepsis. We conclude that both p53-dependent and p53-independent pathways of cell death exist in sepsis. This differential apoptotic response of thymocytes vs splenocytes in p53-/- mice suggests that either the cellular response or the death-inducing signal is cell-type specific in sepsis. The fact that p53-/- lymphocytes of an identical subtype (CD8-CD4+) were protected in thymi but not in spleens indicates that cell susceptibility to apoptosis differs depending upon other unidentified factors.
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Affiliation(s)
- R S Hotchkiss
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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