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Chen AY, Deng CY, Calvachi-Prieto P, Armengol de la Hoz MÁ, Khazi-Syed A, Chen C, Scurlock C, Becker CD, Johnson AEW, Celi LA, Dagan A. A Large-Scale Multicenter Retrospective Study on Nephrotoxicity Associated With Empiric Broad-Spectrum Antibiotics in Critically Ill Patients. Chest 2023; 164:355-368. [PMID: 37040818 PMCID: PMC10475819 DOI: 10.1016/j.chest.2023.03.046] [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: 12/12/2022] [Revised: 03/13/2023] [Accepted: 03/30/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Evidence regarding acute kidney injury associated with concomitant administration of vancomycin and piperacillin-tazobactam is conflicting, particularly in patients in the ICU. RESEARCH QUESTION Does a difference exist in the association between commonly prescribed empiric antibiotics on ICU admission (vancomycin and piperacillin-tazobactam, vancomycin and cefepime, and vancomycin and meropenem) and acute kidney injury? STUDY DESIGN AND METHODS This was a retrospective cohort study using data from the eICU Research Institute, which contains records for ICU stays between 2010 and 2015 across 335 hospitals. Patients were enrolled if they received vancomycin and piperacillin-tazobactam, vancomycin and cefepime, or vancomycin and meropenem exclusively. Patients initially admitted to the ED were included. Patients with hospital stay duration of < 1 h, receiving dialysis, or with missing data were excluded. Acute kidney injury was defined as Kidney Disease: Improving Global Outcomes stage 2 or 3 based on serum creatinine component. Propensity score matching was used to match patients in the control (vancomycin and meropenem or vancomycin and cefepime) and treatment (vancomycin and piperacillin-tazobactam) groups, and ORs were calculated. Sensitivity analyses were performed to study the effect of longer courses of combination therapy and patients with renal insufficiency on admission. RESULTS Thirty-five thousand six hundred fifty-four patients met inclusion criteria (vancomycin and piperacillin-tazobactam, n = 27,459; vancomycin and cefepime, n = 6,371; vancomycin and meropenem, n = 1,824). Vancomycin and piperacillin-tazobactam was associated with a higher risk of acute kidney injury and initiation of dialysis when compared with that of both vancomycin and cefepime (Acute kidney injury: OR, 1.37 [95% CI, 1.25-1.49]; dialysis: OR, 1.28 [95% CI, 1.14-1.45]) and vancomycin and meropenem (Acute kidney injury: OR, 1.27 [95%, 1.06-1.52]; dialysis: OR, 1.56 [95% CI, 1.23-2.00]). The odds of acute kidney injury developing was especially pronounced in patients without renal insufficiency receiving a longer duration of vancomycin and piperacillin-tazobactam therapy compared with vancomycin and meropenem therapy. INTERPRETATION VPT is associated with a higher risk of acute kidney injury than both vancomycin and cefepime and vancomycin and meropenem in patients in the ICU, especially for patients with normal initial kidney function requiring longer durations of therapy. Clinicians should consider vancomycin and meropenem or vancomycin and cefepime to reduce the risk of nephrotoxicity for patients in the ICU.
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Affiliation(s)
- Alyssa Y Chen
- The University of Texas Southwestern Medical School, Dallas, TX; Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA; Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA
| | - Chih-Ying Deng
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA; Department of Bioinformatics, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Paola Calvachi-Prieto
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA; Department of Bioinformatics, Harvard Medical School, Massachusetts General Hospital, Boston, MA
| | - Miguel Ángel Armengol de la Hoz
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA; Cardiovascular Research Center, Harvard Medical School, Massachusetts General Hospital, Boston, MA; Biomedical Engineering and Telemedicine Group, Biomedical Technology Centre CTB, ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | | | - Christina Chen
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Department of Medicine, University of California, San Francisco and San Francisco VA Health Care System, San Francisco, CA
| | - Corey Scurlock
- Department of Medicine and eHealth Center, New York Medical College/Westchester Medical Center, Valhalla, NY
| | - Christian D Becker
- Department of Medicine and eHealth Center, New York Medical College/Westchester Medical Center, Valhalla, NY
| | - Alistair E W Johnson
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA; Department of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alon Dagan
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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Liu X, Armaignac DL, Becker C, Hiddleson C, Dubouchet EM, Rincon T, Amelung PJ, French R, Scurlock C, Atallah L, Badawi O. Improving ICU Risk Predictive Models Through Automation Designed for Resiliency Against Documentation Bias. Crit Care Med 2023; 51:376-387. [PMID: 36576215 DOI: 10.1097/ccm.0000000000005750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Electronic health records enable automated data capture for risk models but may introduce bias. We present the Philips Critical Care Outcome Prediction Model (CCOPM) focused on addressing model features sensitive to data drift to improve benchmarking ICUs on mortality performance. DESIGN Retrospective, multicenter study of ICU patients randomized in 3:2 fashion into development and validation cohorts. Generalized additive models (GAM) with features designed to mitigate biases introduced from documentation of admission diagnosis, Glasgow Coma Scale (GCS), and extreme vital signs were developed using clinical features representing the first 24 hours of ICU admission. SETTING eICU Research Institute database derived from ICUs participating in the Philips eICU telecritical care program. PATIENTS A total of 572,985 adult ICU stays discharged from the hospital between January 1, 2017, and December 31, 2018, were included, yielding 509,586 stays in the final cohort; 305,590 and 203,996 in development and validation cohorts, respectively. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Model discrimination was compared against Acute Physiology and Chronic Health Evaluation (APACHE) IVa/IVb models on the validation cohort using the area under the receiver operating characteristic (AUROC) curve. Calibration assessed by actual/predicted ratios, calibration-in-the-large statistics, and visual analysis. Performance metrics were further stratified by subgroups of admission diagnosis and ICU characteristics. Historic data from two health systems with abrupt changes in Glasgow Coma Scale (GCS) documentation were assessed in the year prior to and after data shift. CCOPM outperformed APACHE IVa/IVb for ICU mortality (AUROC, 0.925 vs 0.88) and hospital mortality (AUROC, 0.90 vs 0.86). Better calibration performance was also attained among subgroups of different admission diagnoses, ICU types, and over unique ICU-years. The CCOPM provided more stable predictions compared with APACHE IVa within an external cohort of greater than 120,000 patients from two health systems with known changes in GCS documentation. CONCLUSIONS These mortality risk models demonstrated excellent performance compared with APACHE while appearing to mitigate bias introduced through major shifts in GCS documentation at two large health systems. This provides evidence to support using automated capture rather than trained personnel for capture of GCS data used in benchmarking ICUs on mortality performance.
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Affiliation(s)
- Xinggang Liu
- Johnson & Johnson, Data Science Portfolio Management, New Brunswick, NJ
| | | | | | | | | | | | | | - Robin French
- Philips, Connected Care, Virtual Care Solutions, Baltimore, MD
| | - Corey Scurlock
- Westchester Medical Center, Valhalla, NY
- New affiliation for Dr. Scurlock: Equum Medical, New York, NY
| | - Louis Atallah
- Philips, Connected Care, Virtual Care Solutions, Baltimore, MD
| | - Omar Badawi
- University of Maryland School of Pharmacy, Baltimore, MD
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Al-Mufti F, Becker C, Kamal H, Alshammari H, Dodson V, Nuoman R, Dakay K, Cooper J, Gulko E, Kaur G, Sahni R, Scurlock C, Mayer SA, Gandhi CD. Acute Cerebrovascular Disorders and Vasculopathies Associated with Significant Mortality in SARS-CoV-2 Patients Admitted to The Intensive Care Unit in The New York Epicenter. J Stroke Cerebrovasc Dis 2021; 30:105429. [PMID: 33276301 PMCID: PMC7605750 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105429] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/21/2020] [Accepted: 10/24/2020] [Indexed: 12/21/2022] Open
Abstract
The current Coronavirus pandemic due to the novel SARS-Cov-2 virus has proven to have systemic and multi-organ involvement with high acuity neurological conditions including acute ischemic strokes. We present a case series of consecutive COVID-19 patients with cerebrovascular disease treated at our institution including 3 cases of cerebral artery dissection including subarachnoid hemorrhage. Knowledge of the varied presentations including dissections will help treating clinicians at the bedside monitor and manage these complications preemptively.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Christian Becker
- Department of Internal Medicine -Division of Pulmonary and Critical Care, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY USA.
| | - Hussein Alshammari
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Vincent Dodson
- Department of Surgery, Rutgers University New Jersey Medical School, Newark, NJ USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Katarina Dakay
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Edwin Gulko
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Internal Medicine -Division of Pulmonary and Critical Care, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Surgery, Rutgers University New Jersey Medical School, Newark, NJ USA; Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595 USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Internal Medicine -Division of Pulmonary and Critical Care, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Surgery, Rutgers University New Jersey Medical School, Newark, NJ USA; Department of Neurosurgery, Westchester Medical Center, Valhalla, NY 10595 USA
| | - Ramandeep Sahni
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Corey Scurlock
- Department of Internal Medicine -Division of Pulmonary and Critical Care, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Stephan A Mayer
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY USA
| | - Chirag D Gandhi
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY USA; Department of Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY USA
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Fusaro MV, Becker C, Miller D, Hassan IF, Scurlock C. ICU Telemedicine Implementation and Risk-Adjusted Mortality Differences Between Daytime and Nighttime Coverage. Chest 2020; 159:1445-1451. [PMID: 33127432 DOI: 10.1016/j.chest.2020.10.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 07/14/2020] [Revised: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND ICU telemedicine augmentation has been associated with improvements in clinical and financial outcomes in many cases, but not all. Understanding this discrepancy is of interest given the clinical impact and intervention cost. A recent meta-analysis noted an association with mortality reduction and standardized mortality ratio (SMR) before ICU telemedicine implementation of > 1. RESEARCH QUESTION Does ICU telemedicine implementation affect adjusted mortality outcomes? If so, in what context? STUDY DESIGN AND METHODS We performed a retrospective pre-post analysis comparing before vs after ICU telemedicine implementation on the outcome of risk-adjusted ICU mortality during am vs pm admissions as well as other objective measures of ICU telemedicine involvement. RESULTS One thousand five hundred eighty-one patient-stays and 14,584 patient-stays were available for analysis in the implementation period before vs after ICU telemedicine implementation, respectively. The average Acute Physiology and Chronic Health Evaluation (APACHE) IVa score was 46.6 vs 54.8 (P < .01) in the am group before ICU telemedicine implementation vs the am group after ICU telemedicine implementation, respectively. The average APACHE IVa score was 47.2 vs 56.3 (P < .01) in the pm group before ICU telemedicine implementation vs the pm group after ICU telemedicine implementation, respectively. Overall, the risk-adjusted ICU mortality was 8.7% before ICU telemedicine implementation vs 6.5% (P < .01) after implementation. When stratified by am and pm admission groups, no significant difference in risk-adjusted ICU mortality was seen in the am stratum. In the pm stratum, risk-adjusted mortality was 10.8% before ICU telemedicine implementation vs 7.0% (P < .01) after ICU telemedicine implementation. The preimplementation SMR in the am admission stratum was 0.95 vs 1.30 in the pm stratum. INTERPRETATION We found a reduction in risk-adjusted ICU mortality with implementation of ICU telemedicine driven predominantly within the pm admission group. The pm admission SMR was 1.30, which may suggest an association with SMR of > 1 before ICU telemedicine implementation and mortality reduction. Future studies should seek to confirm this finding and should explore other important ICU telemedicine outcomes in the context of observed-to-expected ratios.
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Affiliation(s)
- Mario V Fusaro
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network, Valhalla, NY.
| | - Christian Becker
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network, Valhalla, NY
| | - Daniel Miller
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network, Valhalla, NY
| | - Ibrahim F Hassan
- Departments of Medicine and Genetic Medicine, Weill Cornell Medical College, Al Luqta St, Education City, Qatar
| | - Corey Scurlock
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY; Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network, Valhalla, NY; Department of Anesthesiology, Westchester Medical Center Health Network, Valhalla, NY
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Becker CD, Forman L, Gollapudi L, Nevins B, Scurlock C. Rapid Implementation and Adaptation of a Telehospitalist Service to Coordinate and Optimize Care for COVID-19 Patients. Telemed J E Health 2020; 27:388-396. [PMID: 32804055 DOI: 10.1089/tmj.2020.0232] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background/Introduction: The COVID-19 pandemic poses enormous resource challenges to hospitals. Telemedicine is increasingly recognized as an attractive tool to alleviate resource strains. Herein we describe the rapid implementation and sequential process improvement (PI) of a centralized telehospitalist service to coordinate and optimize management of large number of COVID-19 patients in a tertiary and quaternary care hospital very close to the New York City epicenter. Methods: Prospective multidisciplinary PI meetings were held weekly between March 23 and May 10, 2020, and consensus service modifications were implemented for the following week. Inpatient census data, telehospitalist intervention volumes, and service utilization statistics were collected. Results/Discussion: Between March 23 and May 10, 2020, a total of 745 COVID-19 patients were admitted to the general medical wards. The telehospitalist service performed 1,136 audiovisual (AV) patient assessments, 379 best practice interventions, cohorted 108 patients, and conducted 170 remote family conversations. During the consecutive PI cycles, a number of adaptations in AV setup, care standardization, patient logistics, communication, and consultative functions were made to load balance the bedside hospitalist teams. As the COVID-19 hospital census increased to peak levels, the most value was added through facilitation of communication and collaboration between the bedside clinical teams, the infection prevention and control teams, and patient logistics team. Conclusions: A telehospitalist service can be rapidly implemented with basic telemedicine equipment. Processes/this functions can be sequentially adapted to quickly changing needs during conditions such as the COVID-19 pandemic that very quickly can place extraordinary strains on hospital resources.
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Affiliation(s)
- Christian D Becker
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA.,WMCHealth Network eHealth Center, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Leanne Forman
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA.,Division of Hospital Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Lakshmi Gollapudi
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA.,Division of Gastroenterology, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Brooke Nevins
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Corey Scurlock
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA.,WMCHealth Network eHealth Center, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA.,Department of Anesthesiology, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
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6
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Dhaduk K, Miller D, Schliftman A, Athar A, Al Aseri ZA, Echevarria A, Hale B, Scurlock C, Becker C. Implementing and Optimizing Inpatient Access to Dermatology Consultations via Telemedicine: An Experiential Study. Telemed J E Health 2020; 27:68-73. [PMID: 32294027 DOI: 10.1089/tmj.2019.0267] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 11/12/2022] Open
Abstract
Background/Introduction: In-house dermatology consultation services for hospitalized patients are not universally available in acute care hospitals. We encountered an unanticipated access gap for in-person dermatology consultations in our tertiary care hospital that routinely cares for complex high acuity patients with multiple comorbidities. To bridge this gap in specialist expertise in a timely manner, we expeditiously designed and implemented a telemedicine-supported inpatient dermatology consultation service. Methods: We conducted a retrospective review of 155 teledermatology consultations conducted between November 2017 and March 2019 as well as periodic prospective multidisciplinary process improvement meetings to optimize service-associated process maps and workflows. Results: Teledermatology consultations changed the working diagnosis of the primary team in 52.3% of cases and most commonly recommended medical management (61.9% of cases). In total 100% of patients accepted telemedicine support and rated their experience as positive. The first three periodic process improvement meetings led to significant improvements in teledermatology-related process maps and workflows. Discussion: Diagnostic concordance rates between the primary team and the teledermatologist were similar to those reported in the literature for in-person dermatology consultations. Important process improvements include establishing central responsibility of preparing and overseeing the consultation process, mandating the presence of a primary team representative during consultation and patient chart review by the teledermatologist before teleconsultation. Conclusion: Inpatient teledermatology consultation services can be instituted timely and continuously improved to reliably and effectively bridge access gaps, improve diagnostic accuracy and differentiate therapeutic approaches while maintaining patient satisfaction.
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Affiliation(s)
- Kartik Dhaduk
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Daniel Miller
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
- WMCHealth Network eHealth Center, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Alan Schliftman
- WMCHealth Network eHealth Center, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Ammar Athar
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Zohair Ahmed Al Aseri
- Departments of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Alison Echevarria
- WMCHealth Network eHealth Center, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Brian Hale
- WMCHealth Network eHealth Center, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Corey Scurlock
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
- WMCHealth Network eHealth Center, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
- Department of Anesthesiology, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
| | - Christian Becker
- Department of Internal Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
- WMCHealth Network eHealth Center, Westchester Medical Center Health Network and New York Medical College, Valhalla, New York, USA
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Aguilera S, Quintana L, Khan T, Garcia R, Shoman H, Caddell L, Latifi R, Park KB, Garcia P, Dempsey R, Rosenfeld JV, Scurlock C, Crisp N, Samad L, Smith M, Lippa L, Jooma R, Andrews RJ. Global health, global surgery and mass casualties: II. Mass casualty centre resources, equipment and implementation. BMJ Glob Health 2020; 5:e001945. [PMID: 32133170 PMCID: PMC7042577 DOI: 10.1136/bmjgh-2019-001945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 08/27/2019] [Revised: 11/28/2019] [Accepted: 11/30/2019] [Indexed: 02/01/2023] Open
Abstract
Trauma/stroke centres optimise acute 24/7/365 surgical/critical care in high-income countries (HICs). Concepts from low-income and middle-income countries (LMICs) offer additional cost-effective healthcare strategies for limited-resource settings when combined with the trauma/stroke centre concept. Mass casualty centres (MCCs) integrate resources for both routine and emergency care-from prevention to acute care to rehabilitation. Integration of the various healthcare systems-governmental, non-governmental and military-is key to avoid both duplication and gaps. With input from LMIC and HIC personnel of various backgrounds-trauma and subspecialty surgery, nursing, information technology and telemedicine, and healthcare administration-creative solutions to the challenges of expanding care (both daily and disaster) are developed. MCCs are evolving initially in Chile and Pakistan. Technologies for cost-effective healthcare in LMICs include smartphone apps (enhance prehospital care) to electronic data collection and analysis (quality improvement) to telemedicine and drones/robots (support of remote regions and resource optimisation during both daily care and disasters) to resilient, mobile medical/surgical facilities (eg, battery-operated CT scanners). The co-ordination of personnel (within LMICs, and between LMICs and HICs) and the integration of cost-effective advanced technology are features of MCCs. Providing quality, cost-effective care 24/7/365 to the 5 billion who lack it presently makes MCCs an appealing means to achieve the healthcare-related United Nations Sustainable Development Goals for 2030.
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Affiliation(s)
- Sergio Aguilera
- Neurosurgery, Almirante Nef Naval Hospital & Valparaíso University, Viña del Mar, Valparaíso, Chile
| | - Leonidas Quintana
- Neurosurgery, Valparaiso University School of Medicine, Valparaiso, Chile
- World Federation of Neurosurgical Societies, Nyon, Switzerland
| | - Tariq Khan
- World Federation of Neurosurgical Societies, Nyon, Switzerland
- Neurosurgery, Northwest General Hospital and Research Centre, Peshawar, Pakistan
| | - Roxanna Garcia
- Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Haitham Shoman
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Luke Caddell
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
- University of Miami School of Medicine, Miami, Florida, USA
| | - Rifat Latifi
- Surgery, New York Medical College, Valhalla, New York, USA
- International Virtual eHospital Foundation, Hope, Idaho, USA
| | - Kee B Park
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Patricia Garcia
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Robert Dempsey
- Neurosurgery, University of Wisconsin–Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Chair, Foundation for International Education in Neurological Surgery, Madison, Wisconsin, USA
| | - Jeffrey V Rosenfeld
- Neurosurgery, Alfred Hospital, Melbourne, Victoria, Australia
- Royal Australian Army Medical Corps, Melbourne, Victoria, Australia
| | - Corey Scurlock
- Anesthesiology, Internal Medicine, eHealth, Westchester Medical Center, Valhalla, New York, USA
| | - Nigel Crisp
- House of Lords Parliamentary Group on Global Health, London, UK
- Nursing Now, London, UK
| | - Lubna Samad
- Director, Centre for Essential Surgical Network, Indus Health Network, Karachi, Sindh, Pakistan
- Center for Global Health Delivery, Harvard Medical School, Dubai, United Arab Emirates
| | - Montray Smith
- Assistant Professor & HSC Health and Social Justice Scholar, University of Louisville School of Nursing, Louisville, Kentucky, USA
| | - Laura Lippa
- Neurosurgery, Azienda Ospedaliera Universitaria Senese, Siena, Toscana, Italy
| | - Rashid Jooma
- Neurosurgery, Aga Khan University, Karachi, Sindh, Pakistan
- Health Services, Government of Pakistan, Islamabad, Islamabad, Pakistan
| | - Russell J Andrews
- World Federation of Neurosurgical Societies, Nyon, Switzerland
- Nanotechnology and Smart Systems, NASA Ames Research Center, Moffett Field, California, USA
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Khan T, Quintana L, Aguilera S, Garcia R, Shoman H, Caddell L, Latifi R, Park KB, Garcia P, Dempsey R, Rosenfeld JV, Scurlock C, Crisp N, Samad L, Smith M, Lippa L, Jooma R, Andrews RJ. Global health, global surgery and mass casualties. I. Rationale for integrated mass casualty centres. BMJ Glob Health 2019; 4:e001943. [PMID: 31908871 PMCID: PMC6936385 DOI: 10.1136/bmjgh-2019-001943] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 08/30/2019] [Revised: 11/28/2019] [Accepted: 11/30/2019] [Indexed: 01/27/2023] Open
Abstract
It has been well-documented recently that 5 billion people globally lack surgical care. Also well-documented is the need to improve mass casualty disaster response. Many of the United Nations (UN) Sustainable Development Goals (SDGs) for 2030-healthcare and economic milestones-require significant improvement in global surgical care, particularly in low-income and middle-income countries. Trauma/stroke centres evolved in high-income countries with evidence that 24/7/365 surgical and critical care markedly improved morbidity and mortality for trauma and stroke and for cardiovascular events, difficult childbirth, acute abdomen. Duplication of emergency services, especially civilian and military, often results in suboptimal, expensive care. By combining all healthcare resources within the ongoing healthcare system, more efficient care for both individual emergencies and mass casualty situations can be achieved. We describe progress in establishing mass casualty centres in Chile and Pakistan. In both locations, planning among the stakeholders (primarily civilian and military) indicates the feasibility of such integrated surgical and emergency care. We also review other programmes and initiatives to provide integrated mass casualty disaster response. Integrated mass casualty centres are a feasible means to improve both day-to-day surgical care and mass casualty disaster response. The humanitarian aspect of mass casualty disasters facilitates integration among stakeholders-from local healthcare systems to military resources to international healthcare organisations. The benefits of mass casualty centres-both healthcare and economic-can facilitate achieving the 2030 UN SDGs.
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Affiliation(s)
- Tariq Khan
- Chair, Neurotrauma Committee, World Federation of Neurosurgical Societies, Nyon, Switzerland
- Dean and Chair of Neurosurgery, Northwest General Hospital and Research Centre, Peshawar, Pakistan
| | - Leonidas Quintana
- Neurosurgery, Valparaiso University School of Medicine, Valparaiso, Chile
- World Federation of Neurosurgical Societies, Nyon, Switzerland
| | - Sergio Aguilera
- Neurosurgery, Almirante Nef Naval Hospital & Valparaiso University Hospital, Viña del Mar & Valparaiso, Chile
| | - Roxanna Garcia
- Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Haitham Shoman
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Luke Caddell
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Rifat Latifi
- Chair, Department of Surgery, New York Medical College, Valhalla, New York, USA
- Founder & President, International Virtual eHospital Foundation, Hope, Idaho, USA
| | - Kee B Park
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Patricia Garcia
- Professor, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
- Former Minister of Health, Peru
| | - Robert Dempsey
- Professor & Chair, Neurosurgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
- Chair, Foundation for International Education in Neurological Surgery, Madison, Wisconsin, USA
| | - Jeffrey V Rosenfeld
- Senior Neurosurgeon, Alfred Hospital, Melbourne, Victoria, Australia
- Major General, Royal Australian Army Medical Corps, Melbourne, Victoria, Australia
| | - Corey Scurlock
- Professor Anesthesiology/Internal Medicine & Director e-Health, Westchester Medical Center, Valhalla, New York, USA
| | - Nigel Crisp
- Co-Chair, House of Lords Parliamentary Group on Global Health, London, UK
- Co-Chair, Nursing Now, London, UK
| | - Lubna Samad
- Director, Center for Essential Surgical Network, Indus Health Network, Karachi, Sindh, Pakistan
- Center for Global Health Delivery Harvard Medical School, Dubai, United Arab Emirates
| | - Montray Smith
- Assistant Professor and Health & Social Justice Scholar, University of Louisville School of Nursing, Louisville, Kentucky, USA
| | - Laura Lippa
- Neurosurgery, Azienda Ospedaliera Universitaria Senese, Siena, Toscana, Italy
| | - Rashid Jooma
- Neurosurgery, Aga Khan University, Karachi, Sindh, Pakistan
- Former Director General of Health Services, Government of Pakistan, Islamabad, Pakistan
| | - Russell J Andrews
- World Federation of Neurosurgical Societies, Nyon, Switzerland
- Nanotechnology & Smart Systems, NASA Ames Research Center, Moffett Field, California, USA
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Becker CD, Dandy K, Gaujean M, Fusaro M, Scurlock C. Legal Perspectives on Telemedicine Part 2: Telemedicine in the Intensive Care Unit and Medicolegal Risk. Perm J 2019; 23:18.294. [PMID: 31496501 DOI: 10.7812/tpp/18.294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Tele-intensive care unit (tele-ICU) implementation has been shown to improve clinical and financial outcomes. The expansion of this new care delivery model has outpaced the development of its accompanying regulatory framework. In the first part of this commentary we discussed legal and regulatory issues of telemedicine in general and expanded on tele-ICU implementation in particular. Major legal and regulatory barriers to expansion remain, including uncertainty regarding license portability and reimbursement. In this second part we discuss the effects of telemedicine implementation on the various aspects of medicolegal risk and risk mitigation, with a particular focus on tele-ICU. There is a paucity of legal data regarding the effect of tele-ICU implementation on medicolegal risk. We will therefore systematically discuss the effects of tele-ICU on the various root causes of medical error. Given the substantial capital and operational investment that must be undertaken to build and run a tele-ICU, any reduction in risk adds to the financial return on investment and further decreases barriers to implementation.
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Affiliation(s)
- Christian D Becker
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY.,Department of Medicine, Westchester Medical Center, Valhalla, NY.,Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York Medical College, Valhalla
| | - Katherine Dandy
- Law Firm of Brown, Gaujean, Kraus & Sastow, PLLC, White Plains, NY
| | - Max Gaujean
- Law Firm of Brown, Gaujean, Kraus & Sastow, PLLC, White Plains, NY
| | - Mario Fusaro
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY.,Department of Medicine, Westchester Medical Center, Valhalla, NY.,Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York Medical College, Valhalla
| | - Corey Scurlock
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY.,Department of Anesthesiology, Westchester Medical Center, Valhalla, NY.,Department of Anesthesiology, New York Medical College, Valhalla
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Al-Mufti F, Dodson V, Lee J, Wajswol E, Gandhi C, Scurlock C, Cole C, Lee K, Mayer SA. Artificial intelligence in neurocritical care. J Neurol Sci 2019; 404:1-4. [PMID: 31302258 DOI: 10.1016/j.jns.2019.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 04/28/2019] [Revised: 06/16/2019] [Accepted: 06/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neurocritical care combines the management of extremely complex disease states with the inherent limitations of clinically assessing patients with brain injury. As the management of neurocritical care patients can be immensely complicated, the automation of data-collection and basic management by artificial intelligence systems have garnered interest. METHODS In this opinion article, we highlight the potential artificial intelligence has in monitoring and managing several aspects of neurocritical care, specifically intracranial pressure, seizure monitoring, blood pressure, and ventilation. RESULTS The two major AI methods of analytical technique currently exist for analyzing critical care data: the model-based method and data driven method. Both of these methods have demonstrated an ability to analyze vast quantities of patient data, and we highlight the ways in which these modalities of artificial intelligence might one day play a role in neurocritical care. CONCLUSIONS While none of these artificial intelligence systems are meant to replace the clinician's judgment, these systems have the potential to reduce healthcare costs and errors or delays in medical management.
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Affiliation(s)
- Fawaz Al-Mufti
- Departments of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America; Departments of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States of America.
| | - Vincent Dodson
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, United States of America
| | - James Lee
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, United States of America; Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, United States of America
| | - Ethan Wajswol
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, United States of America
| | - Chirag Gandhi
- Departments of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America; Departments of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States of America
| | - Corey Scurlock
- Departments of Anesthesiology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States of America; Departments of Internal Medicine, Westchester Medical Center at New York Medical College, Valhalla, NY, United States of America
| | - Chad Cole
- Departments of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
| | - Kiwon Lee
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, United States of America; Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, United States of America
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States of America
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Abstract
Telemedicine is defined as the remote delivery of clinical care services through audio-visual conferencing technology. A shortage of care practitioners combined with an aging population with disproportionately increasing care utilization patterns has created a "perfect storm," which since the late 1990s has propelled telemedicine as a potential solution to bridge this supply/demand and access gap. In critical care approximately 20% of nonfederal adult intensive care unit (ICU) beds in the US today are supported by some form of tele-ICU coverage. The literature has shown with increasing clarity during the last decade that correct tele-ICU implementation improves outcomes and has the potential to significantly improve the financial performance of health care systems. As is often the case in technology-driven innovations, the legal and regulatory framework has been moving slower than the clinical adoption of this new care delivery model, which is true not just in critical care, but in other medical specialties as well. This 2-part series focuses on legal perspectives on telemedicine. The first part discusses legal and regulatory challenges of telemedicine in general, with a more in-depth focus on tele-ICU. The second part will discuss the effects of telemedicine implementation on medicolegal risk, using the litigious critical care environment as an example.
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Affiliation(s)
- Christian D Becker
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY.,Department of Medicine, Westchester Medical Center, Valhalla, NY.,Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York Medical College, Valhalla
| | - Katherine Dandy
- Law Firm of Brown, Gaujean, Kraus & Sastow, PLLC, White Plains, NY
| | - Max Gaujean
- Law Firm of Brown, Gaujean, Kraus & Sastow, PLLC, White Plains, NY
| | - Mario Fusaro
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY.,Department of Medicine, Westchester Medical Center, Valhalla, NY.,Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York Medical College, Valhalla
| | - Corey Scurlock
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY.,Department of Anesthesiology, Westchester Medical Center, Valhalla, NY.,Department of Anesthesiology, New York Medical College, Valhalla
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12
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Becker CD, Fusaro MV, Scurlock C. Deciphering factors that influence the value of tele-ICU programs. Intensive Care Med 2019; 45:1046-1051. [PMID: 30874824 DOI: 10.1007/s00134-019-05591-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Christian D Becker
- eHealth Center, Westchester Medical Center Health Network, Taylor Pavilion, Room O102, 100 Woods Road, Valhalla, NY, 10595, USA. .,Department of Medicine, Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA. .,Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York Medical College, 40 Sunshine Cottage Road, Valhalla, NY, 10595, USA.
| | - Mario V Fusaro
- eHealth Center, Westchester Medical Center Health Network, Taylor Pavilion, Room O102, 100 Woods Road, Valhalla, NY, 10595, USA.,Department of Medicine, Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA.,Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York Medical College, 40 Sunshine Cottage Road, Valhalla, NY, 10595, USA
| | - Corey Scurlock
- eHealth Center, Westchester Medical Center Health Network, Taylor Pavilion, Room O102, 100 Woods Road, Valhalla, NY, 10595, USA.,Department of Anesthesiology, Westchester Medical Center, 100 Woods Road, Valhalla, NY, 10595, USA.,Department of Anesthesiology, New York Medical College, 40 Sunshine Cottage Road, Valhalla, NY, 10595, USA
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Abstract
Background/Rationale: Patients are admitted to Intensive care units (ICUs) either because they need close monitoring despite a low risk of hospital mortality (LRM group) or to receive ICU specific active treatments (AT group). The characteristics and differential outcomes of LRM patients vs. AT patients in Neurocritical Care Units are poorly understood. Methods: We classified 1,702 patients admitted to our tertiary and quaternary care center Neuroscience-ICU in 2016 and 2017 into LRM vs. AT groups. We compared demographics, admission diagnosis, goal of care status, readmission rates and managing attending specialty extracted from the medical record between groups. Acute Physiology, Age and Chronic Health Evaluation (APACHE) IVa risk predictive modeling was used to assess comparative risks for ICU and hospital mortality and length of stay between groups. Results: 56.9% of patients admitted to our Neuroscience-ICU in 2016 and 2017 were classified as LRM, whereas 43.1% of patients were classified as AT. While demographically similar, the groups differed significantly in all risk predictive outcome measures [APACHE IVa scores, actual and predicted ICU and hospital mortality (p < 0.0001 for all metrics)]. The most common admitting diagnosis overall, cerebrovascular accident/stroke, was represented in the LRM and AT groups with similar frequency [24.3 vs. 21.3%, respectively (p = 0.15)], illustrating that further differentiating factors like symptom duration, neurologic status and its dynamic changes and neuro-imaging characteristics determine the indication for active treatment vs. observation. Patients with intracranial hemorrhage/hematoma were significantly more likely to receive active treatments as opposed to having a primary focus on monitoring [13.6 vs. 9.8%, respectively (p = 0.017)]. Conclusion: The majority of patients admitted to our Neuroscience ICU (56.9%) had <10% hospital mortality risk and a focus on monitoring, whereas the remaining 43.1% of patients received active treatments in their first ICU day. LRM Patients exhibited significantly lower APACHE IVa scores, ICU and hospital mortality rates compared to AT patients. Observed-over-expected ICU and hospital mortality ratios were better than predicted by APACHE IVa for low risk monitored patients and close to prediction for actively treated patients, suggesting that at least a subset of LRM patients may safely and more cost effectively be cared for in intermediate level care settings.
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Affiliation(s)
- Christian D Becker
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY, United States.,Department of Medicine, New York Medical College, Valhalla, NY, United States.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Westchester Medical Center, Valhalla, NY, United States
| | - Christian Bowers
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States.,Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Dipak Chandy
- Department of Medicine, New York Medical College, Valhalla, NY, United States.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Westchester Medical Center, Valhalla, NY, United States
| | - Chad Cole
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States.,Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Meic H Schmidt
- Department of Neurosurgery, New York Medical College, Valhalla, NY, United States.,Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Corey Scurlock
- eHealth Center, Westchester Medical Center Health Network, Valhalla, NY, United States.,Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, United States
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Fusaro MV, Becker C, Pandya S, Mcbride W, Alizadeh K, Iannotti V, Zelkovic P, Barst S, Tobias ME, Mohan A, Freda J, Gewitz M, Scurlock C. International teleconsultation on conjoined twins leading to a successful separation: a case report. J Telemed Telecare 2017; 24:482-484. [DOI: 10.1177/1357633x17715377] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Conjoined twins are identical twins that have incompletely separated in utero. The prognosis for conjoined twins is poor and management in a skilled tertiary care centre is paramount for definitive care. We describe our experience with a telemedical consultation on conjoined twins in The Dominican Republic from our eHealth centre in Valhalla, NY. The patients were two month old, female, pygopagus conjoined twins. A multidisciplinary teleconference was initiated with the patients, their family, the referring paediatrician and our team. Based on this teleconsultation, the team felt as though the twins may be amenable to a surgical separation. They presented to our centre in Valhalla, NY, for a detailed physical examination and series of imaging studies. Soon after, the patients underwent a successful 21 h separation procedure and were discharged 12 weeks later. To our knowledge, this is one of the first reports of an international teleconsultation leading to a successful conjoined twin separation procedure.
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Affiliation(s)
- Mario V Fusaro
- Center for eHealth, New York Medical College, Valhalla, NY, USA
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Christian Becker
- Center for eHealth, New York Medical College, Valhalla, NY, USA
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Samir Pandya
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
- New York Medical College, Valhalla, NY, USA
| | - Whitney Mcbride
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
- New York Medical College, Valhalla, NY, USA
| | - Kaveh Alizadeh
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA
- New York Medical College, Valhalla, NY, USA
| | - Vicki Iannotti
- New York Medical College, Valhalla, NY, USA
- Department of Pediatrics, Maria Fareri Childrens Hospital at Westchester Medical Center, Valhalla, NY, USA
| | - Paul Zelkovic
- New York Medical College, Valhalla, NY, USA
- Department of Urology, Westchester Medical Center, Valhalla, NY, USA
| | - Samuel Barst
- New York Medical College, Valhalla, NY, USA
- Department of Anesthesia, Westchester Medical Center, Valhalla, NY, USA
| | - Michael E Tobias
- New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Avinash Mohan
- New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Jeffrey Freda
- New York Medical College, Valhalla, NY, USA
- Department of Anesthesia, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Gewitz
- New York Medical College, Valhalla, NY, USA
- Department of Pediatrics, Maria Fareri Childrens Hospital at Westchester Medical Center, Valhalla, NY, USA
| | - Corey Scurlock
- Center for eHealth, New York Medical College, Valhalla, NY, USA
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
- Department of Anesthesia, Westchester Medical Center, Valhalla, NY, USA
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15
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Becker C, Frishman WH, Scurlock C. Telemedicine and Tele-ICU: The Evolution and Differentiation of a New Medical Field. Am J Med 2016; 129:e333-e334. [PMID: 27576079 DOI: 10.1016/j.amjmed.2016.05.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Christian Becker
- Center for Telemedicine & eHealth, Westchester Medical Center, Valhalla, NY; Department of Medicine, New York Medical College, Valhalla.
| | | | - Corey Scurlock
- Center for Telemedicine & eHealth, Westchester Medical Center, Valhalla, NY
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16
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Affiliation(s)
- Richard W Carlson
- Medical Intensive Care Unit, Maricopa Medical Center, Phoenix, AZ 85008, USA; College of Medicine, Mayo Clinic, Scottsdale, AZ, USA; University of Arizona College of Medicine, Phoenix, AZ, USA.
| | - Corey Scurlock
- Advanced ICU Care, 747 Third Avenue, Suite 28 A, New York, NY 10017, USA.
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17
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Carlson RW, Scurlock C. Telemedicine in the ICU. Crit Care Clin 2015. [DOI: 10.1016/s0749-0704(15)00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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18
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Kalb T, Raikhelkar J, Meyer S, Ntimba F, Thuli J, Gorman MJ, Kopec I, Scurlock C. A multicenter population-based effectiveness study of teleintensive care unit-directed ventilator rounds demonstrating improved adherence to a protective lung strategy, decreased ventilator duration, and decreased intensive care unit mortality. J Crit Care 2014; 29:691.e7-14. [PMID: 24636928 DOI: 10.1016/j.jcrc.2014.02.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [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] [Received: 08/06/2013] [Revised: 02/15/2014] [Accepted: 02/20/2014] [Indexed: 11/13/2022]
Abstract
PURPOSE OF THE STUDY The purpose of the study is to determine if teleintensive care unit (ICU)-directed daily ventilator rounds improved adherence to lung protective ventilation (LPV), reduced ventilator duration ratio (VDR), and ICU mortality ratios. METHOD USED A retrospective observational longitudinal quarterly analysis of adherence to low tidal volume LPV (<7.5 mL/kg predicted body weight; Pao2/fraction of inspired oxygen<300), ventilator duration, and ICU mortality ratios (Acute Physiology and Chronic Health Evaluation IV-adjusted). The teleICU practice used Philips (Andover, MA) VISICU eCareManagerTM (Andover, MA) platform, providing ICU care and process improvement. RESULTS Before ventilator rounds implementation, there was wide variation in hospital adherence to low tidal volume (29.5±18.2; range 10%-69%). Longitudinal improvement was seen across hospitals in the 3 Qs after implementation, reaching statistical significance by Q3 postimplementation (44.9±15.7; P<.002 by 2-tailed Fisher exact test), maintained at 2 subsequent Qs (48% and 52%; P<.001). Ventilator duration ratio also showed preimplementation variability (1.08±.34; range 0.71-1.90). After implementation, absolute and significant mean VDR reduction was observed (0.92±.28; -15.8%, P<.05). Intensive care unit mortality ratio demonstrated longitudinal improvement, reaching significance after the Q3 postimplementation (0.94 vs 0.67; P<.04), and this was sustained in the most recent Q analyzed (0.65; P<.03). CONCLUSIONS Implementation of teleICU-directed ventilator rounds was associated with improved and durable adherence to LPV and significant reductions in both VDR and ICU mortality.
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Affiliation(s)
- Thomas Kalb
- Department of Medicine, Hofstra School of Medicine, Manhasset, NY; Advanced ICU Care Inc, St Louis, MO.
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19
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Raikhelkar J, Lin HM, Neckman D, Afonso A, Scurlock C. Isolated tricuspid valve surgery: predictors of adverse outcome and survival. Heart Lung Circ 2012; 22:211-20. [PMID: 23103071 DOI: 10.1016/j.hlc.2012.09.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Accepted: 09/27/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Isolated tricuspid valve surgery is a rare operation, for which outcomes are not well defined. We describe a single-centre experience with isolated tricuspid surgery, and an analysis of risk factors for adverse outcome and predictors of survival. METHODS Retrospective analysis of 56 consecutive adult patients undergoing isolated tricuspid valve surgery between November 1998 and November 2010 was performed. RESULTS Eight patients died in hospital (early mortality 14.2%). In comparison with tricuspid repair patients, tricuspid replacement patients required more intraoperative red cell blood transfusion (RBC>1 unit: p=0.033), platelet transfusion (p=0.051), and more postoperative ventilator support (p=0.023). Predictors of early (in hospital) mortality include advanced age (p=0.019) higher euroSCORE (p<0.001), transfusion of intraoperative red blood cells (p=0.005), and cryoprecipitate (p=0.014). Twenty-five patients (44.6%) reached the end-point of death. There was no statistical difference in early and late survival rates between repair and replacement groups. CONCLUSIONS Patients with isolated tricuspid valve surgery continue to be a high-risk group in cardiac surgery with unacceptable operative mortality and limited survival. There were no statistical differences in early and late outcomes between the isolated tricuspid valve repair versus replacement surgery. Timely referral to surgery before the onset of class 3 heart failure, malnutrition, renal dysfunction and age>60 years is recommended.
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Affiliation(s)
- Jayashree Raikhelkar
- Anesthesiology and Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, United States.
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Kalb T, Scurlock C, Lane M, Uhrhan E, Ntimba F, Meyer S, Gorman MJ, Kopec I. Tele-ICU Ventilator Rounds Are Associated With Improved Adherence to Low Tidal Volume Strategy and Decreased Duration of Mechanical Ventilation. Chest 2012. [DOI: 10.1378/chest.1381658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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21
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Raikhelkar JK, Weiss AJ, Maysick L, Scurlock C. Adjuvant Therapy With Methylene Blue in the Treatment of Postoperative Vasoplegic Syndrome Caused by Carcinoid Crisis After Tricuspid Valve Replacement. J Cardiothorac Vasc Anesth 2012; 26:878-9. [DOI: 10.1053/j.jvca.2011.03.180] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Indexed: 11/11/2022]
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24
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Via MA, Scurlock C, Adams DH, Weiss AJ, Mechanick JI. Impaired postoperative hyperglycemic stress response associated with increased mortality in patients in the cardiothoracic surgery intensive care unit. Endocr Pract 2011; 16:798-804. [PMID: 20350912 DOI: 10.4158/ep10017.or] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To describe the association of tight glycemic control with intensive insulin therapy and clinical outcome among patients in the cardiothoracic surgery intensive care unit. METHODS All patients who underwent cardiothoracic surgery and were admitted to the cardiothoracic surgery intensive care unit between September 13, 2007, and November 1, 2007, were enrolled. Clinical and metabolic data were prospectively collected. All patients received intensive insulin therapy using a nurse-driven dynamic protocol targeting blood glucose values of 80 to 110 mg/dL. Four stages of critical illness were defined as follows: acute critical illness (intensive care unit days 0-2), prolonged acute critical illness (intensive care unit 3 or more days), chronic critical illness (tracheotomy performed), and recovery (liberated from ventilator). RESULTS One hundred fourteen patients were enrolled. Seventy-three (64%) recovered during acute critical illness, 26 (23%) recovered during prolonged acute critical illness, and 15 (13%) progressed to chronic critical illness. All 6 deaths were among patients in chronic critical illness. Admission blood glucose and average blood glucose values for the first 12 hours were lower in patients who developed chronic critical illness and died and were higher in patients who developed chronic critical illness and survived (P = .007 and P = .007, respectively). Severe hypoglycemia (blood glucose <40 mg/dL) occurred once (0.03% of all measurements). Lower initial blood glucose values, which reflect an impaired stress response immediately after surgery, were associated with increased mortality, and a significant delay in achieving tight glycemic control with intensive insulin therapy was associated with prolonged intensive care unit course, but no increase in mortality. CONCLUSION The study findings suggest that acute postoperative hyperglycemia and its prompt correction with intensive insulin therapy are associated with favorable outcomes in patients in the cardiothoracic surgery intensive care unit.
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Affiliation(s)
- Michael A Via
- Division of Endocrinology and Metabolism, Albert Einstein College of Medicine, Beth Israel Medical Center, New York, New York, USA.
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Mechanick JI, Scurlock C. Glycemic control and nutritional strategies in the cardiothoracic surgical intensive care unit--2010: state of the art. Semin Thorac Cardiovasc Surg 2011; 22:230-5. [PMID: 21167457 DOI: 10.1053/j.semtcvs.2010.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2010] [Indexed: 01/15/2023]
Abstract
Patients in the cardiothoracic surgical intensive care unit are generally critically ill and undergoing a systemic inflammatory response to cardiopulmonary bypass, ischemia/reperfusion, and hypothermia. This presents several metabolic challenges: hyperglycemia in need of intensive insulin therapy, catabolism, and uncertain gastrointestinal tract function in need of nutritional strategies. Currently, there are controversies surrounding the standard use of intensive insulin therapy and appropriate glycemic targets as well as the use of early enteral nutrition ± parenteral nutrition. In this review, an approach for intensive metabolic support in the cardiothoracic surgical intensive care unit is presented incorporating the most recent clinical evidence. This approach advocates an IIT blood glucose target of 80-110 mg/dL if, it can be implemented safely, with early nutrition support (using parenteral nutrition as needed) to prevent a critical energy debt.
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Affiliation(s)
- Jeffrey I Mechanick
- Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine, New York, New York, USA.
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Raikhelkar JK, Milla F, Darrow B, Scurlock C. Adjuvant Therapy with Methylene Blue in the Treatment of Right Ventricular Failure after Pulmonary Embolectomy. Heart Lung Circ 2011; 20:234-6. [DOI: 10.1016/j.hlc.2010.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Revised: 07/17/2010] [Accepted: 08/30/2010] [Indexed: 11/16/2022]
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Abstract
PURPOSE OF REVIEW Currently the USA has an aging population, with increasing deficits and a healthcare system that most would agree is in need of repair. Finding ways to curtail costs is urgently needed. Attention to glycemic control and metabolic care offers a cost-effective method of treatment to reduce complications. RECENT FINDINGS Healthcare-related expenses occupy an expanding portion of gross domestic product in the US and are a driver of the deficit. Despite all of this spending, the US receives average marks on outcomes and is not obtaining value in its healthcare. Any movements toward healthcare reform must focus on improving outcomes per healthcare dollar spent, and increasing value. The Affordable Care Act will place greater emphasis on preventing complications and reducing hospital-acquired infections. The original Leuven trial demonstrated that proper implementation of glycemic control can reduce morbidity and mortality. More recent studies have shown that there is a cost-benefit to glycemic control as well, through reduction of hospital stay and prevention of complications. On the basis of these changes, physicians who practice metabolic care and provide glycemic control are well positioned to add value in this era of healthcare reform. SUMMARY Glycemic control is inherently valuable in the care of ICU patients as it decreases infectious complications, reduces lengths of stay, and has a positive effect on morbidity and mortality. Further studies should be completed to delineate the exact amount of cost-savings that can be obtained by proper implementation of glycemic control in the ICU.
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Affiliation(s)
- Corey Scurlock
- Department of Anesthesiology, Division of Critical Care, Cardiothoracic Intensive Care Unit, Mount Sinai School of Medicine, New York, New York, USA.
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Scurlock C, Raikhelkar J, Nierman DM. Targeting value in health care: how intensivists can use business principles to make strategic decisions. Physician Exec 2011; 37:18-24. [PMID: 21465890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Corey Scurlock
- Cardiothoracic Intensive Care Unit at Mount Sinai School of Medicine in New York, New York, USA.
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Shapiro M, Scurlock C, Raikhelkar J, Weiss A, Anyanwu A, Schachter EN. Use of Inhaled Epoprostenol in Transition to Extubation in a Patient After Implantation of a Ventricular Assist Device. J Cardiothorac Vasc Anesth 2010; 24:988-9. [DOI: 10.1053/j.jvca.2009.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2009] [Indexed: 11/11/2022]
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Raikhelkar J, Anyanwu A, Gist RS, Somal J, Mechanick JI, Scher C, Scurlock C. Pheochromocytoma Presenting as Severe Biventricular Failure Requiring Insertion of a Biventricular Assist Device. J Cardiothorac Vasc Anesth 2010; 24:985-7. [DOI: 10.1053/j.jvca.2009.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Indexed: 11/11/2022]
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Raikhelkar JK, Reich DL, Schure R, Varghese R, Bodian C, Scurlock C. The Efficacy of Post-Cardiopulmonary Bypass Dosing of Vancomycin in Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2010; 14:301-4. [DOI: 10.1177/1089253210383337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. Vancomycin is administered widely to patients undergoing cardiac surgery as prophylaxis against resistant Gram-positive sternal wound and venous donor site infections. The purpose of this study was to determine the efficacy of a standardized prebypass and postbypass dosing regimen of vancomycin by assessing plasma concentrations in the immediate postoperative period and postoperative surgical site infections (SSIs). Design. Retrospective cohort study. Setting . Cardiothoracic surgical intensive care unit in a tertiary care academic medical center. Methods. A total of 34 consecutive adult patients who had undergone cardiac surgery with cardiopulmonary bypass (CPB) were analyzed retrospectively. Each patient received 1000 mg of vancomycin administered over 1 hour around the time of induction of anesthesia and 500 mg after discontinuation of CPB. Trough vancomycin levels were sampled in the intensive care unit 12 hours after the last dose given in the operating room. Along with patient characteristics, postoperative readmission rates and SSIs were recorded for 1 year after surgery. Results. The nadir serum vancomycin level before the next dose was 9.3 ± 4.5 µg/mL (mean ± standard deviation). One superficial SSI was noted. Readmission rate for SSIs was 2.94%. Conclusion . Vancomycin concentrations in the serum were greater than the minimum inhibitory concentration for most staphylococci ranging from 4 to 19.3 µg/mL producing acceptable therapeutic serum concentrations and low rate of infectious complications. Thus postbypass dosing is acceptable in vancomycin cardiac surgical prophylaxis.
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Affiliation(s)
| | | | | | | | - Carol Bodian
- Mount Sinai School of Medicine, New York, NY, USA
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Afonso A, Scurlock C, Reich D, Raikhelkar J, Hossain S, Bodian C, Krol M, Flynn B. Predictive Model for Postoperative Delirium in Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth 2010; 14:212-7. [DOI: 10.1177/1089253210374650] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Delirium is a common complication following cardiac surgery, and the predictors of delirium remain unclear. The authors performed a prospective observational analysis to develop a predictive model for postoperative delirium using demographic and procedural parameters. A total of 112 adult postoperative cardiac surgical patients were evaluated twice daily for delirium using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Model for the ICU (CAM-ICU). The incidence of delirium was 34% (n = 38). Increased age (odds ratio [OR] = 2.5; 95% confidence interval [CI] = 1.6-3.9; P < .0001, per 10 years) and increased duration of surgery (OR = 1.3; 95% CI = 1.1-1.5; P = .0002, per 30 minutes) were independently associated with postoperative delirium. Gender, BMI, diabetes mellitus, preoperative ejection fraction, surgery type, length of cardiopulmonary bypass, intraoperative blood component administration, Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, and Charlson Comorbidity Index, were not independently associated with postoperative delirium.
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Affiliation(s)
| | | | - David Reich
- Mount Sinai School of Medicine, New York, NY, USA
| | | | | | - Carol Bodian
- Mount Sinai School of Medicine, New York, NY, USA
| | - Marina Krol
- Mount Sinai School of Medicine, New York, NY, USA
| | - Brigid Flynn
- Mount Sinai School of Medicine, New York, NY, USA,
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Raikhelkar JK, Scurlock C. Letter by Raikhelkar and Scurlock regarding article, "Determinants of surgical outcome in patients with isolated tricuspid regurgitation". Circulation 2010; 122:e14; author reply e15. [PMID: 20625140 DOI: 10.1161/circulationaha.109.918243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Di Luozzo G, Scurlock C, Mechanick JI, Griepp RB. Extracorporeal Peritoneovenous Shunt for the Management of Postaneurysmectomy Chylous Ascites in a Marfan Patient. Ann Thorac Surg 2010; 90:281-4. [DOI: 10.1016/j.athoracsur.2009.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 09/18/2009] [Accepted: 12/02/2009] [Indexed: 11/30/2022]
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Krishan K, Raikhelkar J, Stelzer P, Scurlock C. Chronic Mitral Stenosis. Ann Thorac Surg 2010; 89:e28. [DOI: 10.1016/j.athoracsur.2010.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 01/07/2010] [Accepted: 01/21/2010] [Indexed: 10/19/2022]
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Scurlock C, Raikhelkar J, Mechanick JI. Critique of normoglycemia in intensive care evaluation: survival using glucose algorithm regulation (NICE-SUGAR)--a review of recent literature. Curr Opin Clin Nutr Metab Care 2010; 13:211-4. [PMID: 20010098 DOI: 10.1097/mco.0b013e32833571f4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE OF REVIEW The publication of the long awaited results of the Normoglycaemia in Intensive Care Evaluation - Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial generated intense controversy in the area of glycemic control in the critically ill. NICE-SUGAR reported results in direct contrast to the original Leuven study and challenged the legitimacy of a mortality benefit of tight glycemic control in the intensive care unit (ICU). This review of the recent literature critically examines the salient differences between NICE-SUGAR and the original Leuven study. RECENT FINDINGS Differences in glycemic targets within the control and intervention groups, variability with patients reaching these set targets, and the disparity in study execution and nutritional strategies are some of the methodological differences explaining the observed differences in mortality and morbidity between the two studies. The Leuven study should be viewed as a 'proof-of-concept' study with future studies aimed at confirming its finding and optimizing clinical algorithms to safely implement it in various 'real world' settings. Discrepancies in implementation and nutrition make direct comparison of NICE-SUGAR and the original Leuven study impracticable. SUMMARY Accurate replication of the original Leuven methodology may be the limiting factor for achieving the benefits gained by intensive insulin therapy (IIT). Determination of ICU capability (physicians, nurses, standardization of equipment, etc.) is crucial to implementing tight glycemic targets. If IIT is not achievable due to adverse outcomes such as hypoglycemia, more lax and reachable glucose control should be sought.
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Affiliation(s)
- Corey Scurlock
- Department of Anesthesiology and Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Abstract
OBJECTIVE To describe a new aspect of critical care termed intensive metabolic support. METHODS We performed a MEDLINE search of the English-language literature published between 1995 and 2008 for studies regarding the metabolic stages of critical illness, intensive insulin treatment, and intensive metabolic support in the intensive care unit, and we summarize the clinical data. RESULTS Intensive metabolic support is a 3-component model involving metabolic control and intensive insulin therapy, early nutrition support, and nutritional pharmacology aimed at preventing allostatic overload and the development of chronic critical illness. To improve clinical outcome and prevent mortality, intensive metabolic support should start on arrival to the intensive care unit and should end only when patients are in the recovery phase of their illness. CONCLUSIONS Intensive metabolic support should be an essential part of the daily treatment strategy in critical care medicine. This will involve a newfound and extensive collaboration between the endocrinologist and the intensivist. We call for well-designed future studies involving implementation of this protocol to decrease the burden of chronic critical illness.
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Affiliation(s)
- Corey Scurlock
- Cardiothoracic Surgical Intensive Care Unit, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Abstract
PURPOSE OF REVIEW Technological innovations in the ICU have lead to extraordinary advances in modern critical care. Renal replacement therapy (RRT) innovations and ventricular assist devices (VAD) are now becoming common interventions in the ICU environment. The purpose of this article is to describe the impact of RRT and VAD on critical care medicine with particular reference to metabolic care. RECENT FINDINGS Continuous venovenous hemofiltration and slow low efficient daily dialysis are effective modalities of RRT in hemodynamically unstable patients. These continuous forms of RRT can result in accentuated protein and nutrient losses but also provide an opportunity for intradialytic parenteral nutrition support. VAD patients typically have cardiac cachexia and develop chronic critical illness syndrome. Intensive metabolic support, incorporating trophic, concentrated, semielemental enteral nutrition, supplemental parenteral nutrition, and intensive insulin therapy is a rational strategy to implement in VAD patients. Unfortunately, there is insufficient evidence at this time to support the routine use of these nutritional interventions with RRT and VAD. SUMMARY Patients requiring RRT or VAD are at high nutritional risk, which negatively affects ICU outcome. Prompt nutritional risk assessment and early optimization of metabolic care is crucial in this patient population.
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Affiliation(s)
- Corey Scurlock
- Cardiothoracic Surgical Intensive Care Unit, Department of Anesthesiology and Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Stone ME, Yun J, Chui I, Scurlock C. Successful conservative management of a tracheal tear in a septic octogenarian. J Cardiothorac Vasc Anesth 2008; 23:513-4. [PMID: 19054691 DOI: 10.1053/j.jvca.2008.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Indexed: 11/11/2022]
Affiliation(s)
- Marc E Stone
- Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029, USA
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Via M, Scurlock C, Raikhelkar J, Di Luozzo G, Mechanick JI. Chromium infusion reverses extreme insulin resistance in a cardiothoracic ICU patient. Nutr Clin Pract 2008; 23:325-8. [PMID: 18595867 DOI: 10.1177/0884533608318676] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Insulin resistance is common and often multifactorial in acutely critically ill patients. At our institution, glycemic control is achieved in these patients using an intravenous insulin protocol. The authors present a case in which a patient developed severe insulin resistance following surgical repair of a thoracic aorta aneurysm. Postoperatively, the patient required 2110 units of insulin over 40 hours while receiving pressors and glucocorticoids. After the administration of intravenous chromium at 3 microg/h, the blood sugar normalized and insulin therapy was discontinued. This case represents a unique approach using intravenous chromium to achieve glycemic control in a patient with extreme insulin resistance and acute critical illness. Prospective clinical trials using intravenous chromium may provide the means to optimize intensive insulin therapy for critically ill patients.
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Affiliation(s)
- Michael Via
- Mount Sinai School of Medicine, Endocrinology, New York, NY 10128, USA
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Abstract
PURPOSE OF REVIEW Early nutrition support, defined as within the first 24-48 h of ICU care, is recommended by clinical practice guidelines. The purpose of this paper is to provide an evidence-based US perspective on early nutrition support in critical illness, explain its mechanism of action, and describe its implementation using combined enteral and parenteral nutrition support. RECENT FINDINGS Recent American and Canadian guidelines recommend starting enteral nutrition within the first 24-48 h of ICU care. This is mainly due to accrued 'energy debt' from underfeeding in certain patients. This energy debt leads to increased risks of complications and longer lengths of stay. Strong clinical evidence, however, in the form of prospective, randomized, controlled intervention studies of early nutrition support in the setting of routine intensive insulin therapy, is lacking. SUMMARY Early enteral nutrition should be first-line therapy in the ICU. If a caloric goal of 20-25 kcal/kg/day is not possible, then combined enteral and parenteral nutrition should be started. In the new age of intensive insulin therapy, parenteral nutrition has not been shown to confer significant additional infective risk. There are many unanswered questions, but a proactive posture for metabolic support in the ICU is advocated.
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Affiliation(s)
- Corey Scurlock
- Cardiothoracic Intensive Care Unit, Department of Anesthesiology and Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Filsoufi F, Rahmanian PB, Castillo JG, Scurlock C, Legnani PE, Adams DH. Predictors and outcome of gastrointestinal complications in patients undergoing cardiac surgery. Ann Surg 2007; 246:323-9. [PMID: 17667513 PMCID: PMC1933566 DOI: 10.1097/sla.0b013e3180603010] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the incidence and independent predictors of gastrointestinal complications (GICs) following cardiac surgery. SUMMARY BACKGROUND DATA Gastrointestinal ischemia and hemorrhage represent a rare but devastating complication following heart surgery. The profile of patients referred for cardiac surgery has changed during the last decade, questioning the validity of previously reported incidence and risk factors. METHODS We retrospectively analyzed prospectively collected data from 4819 patients undergoing cardiac surgery between 1998 and 2004. Patients with GICs were compared with the entire patient population. Study endpoints were mortality, postoperative morbidities, and long-term survival. RESULTS GICs occurred in 51 (1.1%) patients. Etiologies were intestinal ischemia (n = 30; 59%) and hemorrhage (n = 21; 41%). The incidence decreased during the study period (1998-2001: 1.3%, 2002-2004: 0.7%; P = 0.04). The incidence per type of procedure was as follows: coronary artery bypass grafting (CABG)/valve (2.4%), aortic surgery (1.7%), valve surgery (1.0%), and CABG (0.5%; P = 0.001). Multivariate analysis revealed age (odds ratio [OR] = 2.1), myocardial infarction (OR = 2.5), CHF (OR = 2.4), hemodynamic instability (OR = 2.8), cardiopulmonary bypass time >120 minutes (OR = 6.2), peripheral vascular disease (OR = 2.2), renal (OR = 3.2), and hepatic failure (OR = 10.8) as independent predictors of GICs. The overall hospital mortality among patients with GICs was 33%. Long-term survival was significantly decreased in patients with GICs compared with the control group. CONCLUSIONS Gastrointestinal complications following cardiac surgery remain rare with an incidence <1% in a contemporary series. The key to a lower incidence of GICs lies in systematic application of preventive measures and new advances in intraoperative management. Identification of independent risk factors would facilitate the determination of patients who would benefit from additional perioperative monitoring. Future resources should therefore be redirected to mitigate GICs in high-risk patients.
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Affiliation(s)
- Farzan Filsoufi
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Filsoufi F, Castillo JG, Rahmanian PB, Scurlock C, Fischer G, Adams DH. Effective Management of Refractory Postcardiotomy Bleeding With the Use of Recombinant Activated Factor VII. Ann Thorac Surg 2006; 82:1779-83. [PMID: 17062247 DOI: 10.1016/j.athoracsur.2006.05.076] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Revised: 05/12/2006] [Accepted: 05/16/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Severe coagulopathy after cardiovascular surgery may lead to intractable bleeding and is associated with increased mortality and morbidity. Recent studies have suggested that recombinant activated factor VII (rFVIIa) may play a role in decreasing postoperative bleeding. Herein we report our experience with the off-label use of rFVIIa in patients with refractory postcardiotomy bleeding. METHODS From June 2003 to December 2005, 17 patients (mean age, 65 +/- 18 years) received rFVIIa for refractory bleeding after cardiac surgery. Preoperative risk factors for bleeding included reoperation (n = 7), emergency surgery (n = 7), and renal or hepatic failure (n = 3). Surgical procedures were aortic surgery (n = 7), complex valve operations (n = 7), coronary artery bypass grafting (n = 2), and cardiac tumor resection (n = 1). RESULTS The average dose of rFVIIa was 103.1 +/- 30.2 microg/kg. After the administration of rFVIIa the blood loss was reduced and chest tube output decreased from an average of 300 mL/h to 60 mL/h (p = 0.024). Coagulation variables normalized (mean prothrombin time, 18 +/- 7 versus 14 +/- 3 seconds; p = 0.03; mean partial thromboplastin time, 94 +/- 50 versus 49 +/- 14 seconds; p = 0.02), and the need for blood products was significantly reduced. Only 1 patient required mediastinal reexploration. No thromboembolic complications occurred during hospitalization. CONCLUSIONS This study suggests that rFVIIa is safe and efficacious in the management of refractory postcardiotomy bleeding. The use of rFVIIa is associated with reduced blood loss, rapid improvement of coagulation variables, and decreased need for blood products. Further studies are necessary to determine the safety and efficacy of this new hemostatic agent and its precise role in the treatment of severe postoperative coagulopathy.
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Affiliation(s)
- Farzan Filsoufi
- Department of Cardiothoracic Surgery, Mount Sinai Hospital, New York, New York 10029, USA.
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Abstract
BACKGROUND The "To Err is Human" report published by the Institute of Medicine (IOM) in 1999 called for a national effort to make health care safer. Although the report has been widely credited with spawning efforts to study and improve safety in health care, there has been limited objective assessment of its impact. We evaluated the effects of the IOM report on patient safety publications and research awards. METHODS We searched MEDLINE to identify English language articles on patient safety and medical errors published between 1 November 1994 and 1 November 2004. Using interrupted time series analyses, changes in the number, type, and subject matter of patient safety publications were measured. We also examined federal (US only) funding of patient safety research awards for the fiscal years 1995-2004. RESULTS A total of 5514 articles on patient safety and medical errors were published during the 10 year study period. The rate of patient safety publications increased from 59 to 164 articles per 100,000 MEDLINE publications (p<0.001) following the release of the IOM report. Increased rates of publication were observed for all types of patient safety articles. Publications of original research increased from an average of 24 to 41 articles per 100,000 MEDLINE publications after the release of the report (p<0.001), while patient safety research awards increased from 5 to 141 awards per 100,000 federally funded biomedical research awards (p<0.001). The most frequent subject of patient safety publications before the IOM report was malpractice (6% v 2%, p<0.001) while organizational culture was the most frequent subject (1% v 5%, p<0.001) after publication of the report. CONCLUSIONS Publication of the report "To Err is Human" was associated with an increased number of patient safety publications and research awards. The report appears to have stimulated research and discussion about patient safety issues, but whether this will translate into safer patient care remains unknown.
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Affiliation(s)
- H T Stelfox
- Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Abstract
Aggression has been previously correlated with impulsive personality. In the present study, Barratt Impulsiveness Scale (BIS) scores of 40 male controls aged 15-40 years were related to the frequency of free-operant aggressive and escape responses toward a fictitious antagonist. Participants earned "points" worth money with repeated button presses on a fixed-ratio schedule and were provoked by the periodic subtraction of a point. These subtractions were blamed on the behavior of a (fictitious) other participant, and aggressive responses (presses of a separate button) were defined as those emitted by the participant with an intent to subtract earnings from the other (fictitious) participant. BIS scores were not correlated with frequency of point-subtracting (aggressive) responses to the point subtractions, but they were correlated with the frequency of escape responses on a third button, which the participant was told would protect his points from subtraction for an unspecified period of time. These results suggest that among normal controls, impulsivity might be characterized by some sensitivity to aversive stimuli.
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Affiliation(s)
- J M Bjork
- Department of Psychiatry & Behavioral Sciences, University of Texas-Houston 77030, USA
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