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Tomlinson G, Al-Khafaji A, Conrad SA, Factora FNF, Foster DM, Galphin C, Gunnerson KJ, Khan S, Kohli-Seth R, McCarthy P, Meena NK, Pearl RG, Rachoin JS, Rains R, Seneff M, Tidswell M, Walker PM, Kellum JA. Correction to: Bayesian methods: a potential path forward for sepsis trials. Crit Care 2024; 28:11. [PMID: 38172963 PMCID: PMC10765909 DOI: 10.1186/s13054-023-04791-1] [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] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Affiliation(s)
- George Tomlinson
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA
| | - Steven A Conrad
- Departments of Medicine, Emergency Medicine, Pediatrics and Surgery, Louisiana State University Health, Shreveport, LA, USA
| | - Faith N F Factora
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA
| | | | - Claude Galphin
- Southeast Renal Research Institute, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Sobia Khan
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul McCarthy
- West Virginia University, Heart & Vascular Institute, Morgantown, WV, USA
| | - Nikhil K Meena
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jean-Sebastien Rachoin
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Ronald Rains
- Pulmonary Associates, Univ of Colorado Health-Memorial Hospital, Colorado Springs, CO, USA
| | - Michael Seneff
- Department of Anesthesia and Critical Care, George Washington University Hospital, Washington, DC, USA
| | - Mark Tidswell
- Pulmonary and Critical Care Division, Baystate Medical Center, Springfield, MA, USA
| | | | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA.
- Spectral Medical Inc, Toronto, ON, Canada.
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Tomlinson G, Al-Khafaji A, Conrad SA, Factora FNF, Foster DM, Galphin C, Gunnerson KJ, Khan S, Kohli-Seth R, McCarthy P, Meena NK, Pearl RG, Rachoin JS, Rains R, Seneff M, Tidswell M, Walker PM, Kellum JA. Bayesian methods: a potential path forward for sepsis trials. Crit Care 2023; 27:432. [PMID: 37940985 PMCID: PMC10634134 DOI: 10.1186/s13054-023-04717-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Given the success of recent platform trials for COVID-19, Bayesian statistical methods have become an option for complex, heterogenous syndromes like sepsis. However, study design will require careful consideration of how statistical power varies using Bayesian methods across different choices for how historical data are incorporated through a prior distribution and how the analysis is ultimately conducted. Our objective with the current analysis is to assess how different uses of historical data through a prior distribution, and type of analysis influence results of a proposed trial that will be analyzed using Bayesian statistical methods. METHODS We conducted a simulation study incorporating historical data from a published multicenter, randomized clinical trial in the US and Canada of polymyxin B hemadsorption for treatment of endotoxemic septic shock. Historical data come from a 179-patient subgroup of the previous trial of adult critically ill patients with septic shock, multiple organ failure and an endotoxin activity of 0.60-0.89. The trial intervention consisted of two polymyxin B hemoadsorption treatments (2 h each) completed within 24 h of enrollment. RESULTS In our simulations for a new trial of 150 patients, a range of hypothetical results were observed. Across a range of baseline risks and treatment effects and four ways of including historical data, we demonstrate an increase in power with the use of clinically defensible incorporation of historical data. In one possible trial result, for example, with an observed reduction in risk of mortality from 44 to 37%, the probability of benefit is 96% with a fixed weight of 75% on prior data and 90% with a commensurate (adaptive-weighting) prior; the same data give an 80% probability of benefit if historical data are ignored. CONCLUSIONS Using Bayesian methods and a biologically justifiable use of historical data in a prior distribution yields a study design with higher power than a conventional design that ignores relevant historical data. Bayesian methods may be a viable option for trials in critical care medicine where beneficial treatments have been elusive.
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Affiliation(s)
- George Tomlinson
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA
| | - Steven A Conrad
- Departments of Medicine, Emergency Medicine, Pediatrics and Surgery, Louisiana State University Health, Shreveport, LA, USA
| | - Faith N F Factora
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH, USA
| | | | - Claude Galphin
- Southeast Renal Research Institute, CHI Memorial Hospital, Chattanooga, TN, USA
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Sobia Khan
- Department of Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul McCarthy
- West Virginia University, Heart & Vascular Institute, Morgantown, WV, USA
| | - Nikhil K Meena
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jean-Sebastien Rachoin
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Ronald Rains
- Pulmonary Associates, Univ of Colorado Health-Memorial Hospital, Colorado Springs, CO, USA
| | - Michael Seneff
- Department of Anesthesia and Critical Care, George Washington University Hospital, Washington, DC, USA
| | - Mark Tidswell
- Pulmonary and Critical Care Division, Baystate Medical Center, Springfield, MA, USA
| | | | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 600 Scaife Hall, Pittsburgh, PA, 15261, USA.
- Spectral Medical Inc, Toronto, ON, Canada.
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Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LKN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient: Executive Summary. Crit Care Med 2023; 51:1407-1410. [PMID: 37707378 DOI: 10.1097/ccm.0000000000005999] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Jarrod M Mosier
- Department of Emergency Medicine and Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Asad E Patanwala
- Faculty of Medicine and Health, Sydney School of Pharmacy, The University of Sydney, Sydney, Australia
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers University, New Brunswick, NJ
| | - John M Oropello
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan P Bodkin
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY
| | - Kevin A Kaucher
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | | | - Edward M Manno
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Stephen A Mayer
- Departments of Neurology and Neurosurgery Westchester Medical Center, New York Medical College, New York, NY
| | - Lars-Kristofer N Peterson
- Departments of Critical Care Medicine and Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Jeremy Fulmer
- Respiratory Care Services, Geisinger Medical Center, Danville, PA
| | - Christopher Galton
- Departments of Anesthesiology and Perioperative Medicine and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Thomas P Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Karin Chase
- Departments of Surgery and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alan C Heffner
- Departments of Critical Care and Emergency Medicine, Atrium Healthcare System, Charlotte, NC
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Bryan Boling
- Department of Anesthesiology, Division of Critical Care Medicine, University of Kentucky, Lexington, KY
| | - Michael J Murray
- Departments of Anesthesiology and Internal Medicine/Cardiology, University of Arizona College of Medicine, Phoenix, AZ
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Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LKN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med 2023; 51:1411-1430. [PMID: 37707379 DOI: 10.1097/ccm.0000000000006000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
RATIONALE Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Jarrod M Mosier
- Department of Emergency Medicine and Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Asad E Patanwala
- Faculty of Medicine and Health, Sydney School of Pharmacy, The University of Sydney, Sydney, Australia
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers University, New Brunswick, NJ
| | - John M Oropello
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan P Bodkin
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York, NY
| | - Kevin A Kaucher
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | | | - Edward M Manno
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Stephen A Mayer
- Departments of Neurology and Neurosurgery Westchester Medical Center, New York Medical College, New York, NY
| | - Lars-Kristofer N Peterson
- Departments of Critical Care Medicine and Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Jeremy Fulmer
- Respiratory Care Services, Geisinger Medical Center, Danville, PA
| | - Christopher Galton
- Departments of Anesthesiology and Perioperative Medicine and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Thomas P Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Karin Chase
- Departments of Surgery and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alan C Heffner
- Departments of Critical Care and Emergency Medicine, Atrium Healthcare System, Charlotte, NC
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Bryan Boling
- Department of Anesthesiology, Division or Critical Care Medicine, University of Kentucky, Lexington, KY
| | - Michael J Murray
- Departments of Anesthesiology and Internal Medicine/Cardiology, University of Arizona College of Medicine, Phoenix, AZ
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Koyner JL, Chawla LS, Bihorac A, Gunnerson KJ, Schroeder R, Demirjian S, Hodgson L, Frey JA, Wilber ST, Kampf JP, Kwan T, McPherson P, Kellum JA. Performance of a Standardized Clinical Assay for Urinary C-C Motif Chemokine Ligand 14 (CCL14) for Persistent Severe Acute Kidney Injury. Kidney360 2022; 3:1158-1168. [PMID: 35919538 PMCID: PMC9337886 DOI: 10.34067/kid.0008002021] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/07/2022] [Indexed: 01/11/2023]
Abstract
Background Clinical use of biomarkers requires the development of standardized assays and establishment of cutoffs. Urinary C-C motif chemokine ligand 14 (CCL14) has been validated to predict persistent severe AKI in critically ill patients with established AKI. We now report on the performance of standardized cutoffs using a clinical assay. Methods A second aim of the multicenter RUBY Study was to establish two cutoffs for the prediction of persistent severe AKI (defined as KDIGO stage 3 AKI for at least 72 consecutive hours). Patients who received renal replacement therapy (RRT) or died before achieving 72 hours in stage 3 AKI were also considered to have reached the end point. Results A cutoff value for urinary CCL14 of 1.3 ng/ml was determined to achieve high sensitivity (91%; 95% CI, 84% to 96%), and 13 ng/ml achieved high specificity (93%; 95% CI, 89% to 96%). The cutoff of 1.3 ng/ml identifies the majority (91%) of patients who developed persistent severe AKI with a negative predictive value of 92%. The cutoff at 13 ng/ml had a positive predictive value of 72% (with a negative predictive value of 75%). In multivariable adjusted analyses, a CCL14 concentration between 1.3 and 13 ng/ml had an adjusted odds ratio (aOR) of 3.82 (95% CI, 1.73 to 9.12; P=0.001) for the development of persistent severe AKI compared with those with a CCL14 ≤1.3 ng/ml, whereas a CCL14 >13 ng/ml had an aOR of 10.4 (95% CI, 3.89 to 29.9; P<0.001). Conclusions Using a clinical assay, these standardized cutoffs (1.3 and 13 ng/ml) allow for the identification of patients at high risk for the development of persistent severe AKI. These results have immediate utility in helping to guide AKI patient care and may facilitate future clinical trials.Clinical Trial registry name and registration number: Identification and Validation of Biomarkers of Acute Kidney Injury Recovery, NCT01868724.
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Affiliation(s)
- Jay L. Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | | | - Azra Bihorac
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida
| | - Kyle J. Gunnerson
- Department of Emergency Medicine, University of Michigan Health, Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, Michigan
| | - Rebecca Schroeder
- Department of Anesthesiology, Duke University School of Medicine, VA Health Care System, Durham, North Carolina
| | - Sevag Demirjian
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - Luke Hodgson
- Worthing Hospital, University Hospitals Sussex, Worthing, United Kingdom
| | - Jennifer A. Frey
- Department of Emergency Medicine, Ohio State University, Columbus, Ohio
| | - Scott T. Wilber
- Mount Carmel East Hospital, Mount Carmel Health System, Columbus, Ohio
| | | | | | | | - John A. Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania
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6
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Hsu CH, Meurer WJ, Domeier R, Fowler J, Whitmore SP, Bassin BS, Gunnerson KJ, Haft JW, Lynch WR, Nallamothu BK, Havey RA, Kidwell KM, Stacey WC, Silbergleit R, Bartlett RH, Neumar RW. Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest (EROCA): Results of a Randomized Feasibility Trial of Expedited Out-of-Hospital Transport. Ann Emerg Med 2021; 78:92-101. [PMID: 33541748 PMCID: PMC8238799 DOI: 10.1016/j.annemergmed.2020.11.011] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 01/14/2023]
Abstract
STUDY OBJECTIVE Outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest depend on time to therapy initiation. We hypothesize that it would be feasible to select refractory out-of-hospital cardiac arrest patients for expedited transport based on real-time estimates of the 911 call to the emergency department (ED) arrival interval, and for emergency physicians to rapidly initiate ECPR in eligible patients. METHODS In a 2-tiered emergency medical service with an ECPR-capable primary destination hospital, adults with refractory shockable or witnessed out-of-hospital cardiac arrest were randomized 4:1 to expedited transport or standard care if the predicted 911 call to ED arrival interval was less than or equal to 30 minutes. The primary outcomes were the proportion of subjects with 911 call to ED arrival less than or equal to 30 minutes and ED arrival to ECPR flow less than or equal to 30 minutes. RESULTS Of 151 out-of-hospital cardiac arrest 911 calls, 15 subjects (10%) were enrolled. Five of 12 subjects randomized to expedited transport had an ED arrival time of less than or equal to 30 minutes (overall mean 32.5 minutes [SD 7.1]), and 5 were eligible for and treated with ECPR. Three of 5 ECPR-treated subjects had flow initiated in less than or equal to 30 minutes of ED arrival (overall mean 32.4 minutes [SD 10.9]). No subject in either group survived with a good neurologic outcome. CONCLUSION The Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest trial did not meet predefined feasibility outcomes for selecting out-of-hospital cardiac arrest patients for expedited transport and initiating ECPR in the ED. Additional research is needed to improve the accuracy of predicting the 911 call to ED arrival interval, optimize patient selection, and reduce the ED arrival to ECPR flow interval.
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Affiliation(s)
- Cindy H Hsu
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Department of Neurology, University of Michigan Medical School, Ann Arbor, MI
| | - Robert Domeier
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Saint Joseph Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer Fowler
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sage P Whitmore
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - William R Lynch
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Renee A Havey
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
| | - William C Stacey
- Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Robert H Bartlett
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Robert W Neumar
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
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Kellum JA, Artigas A, Gunnerson KJ, Honore PM, Kampf JP, Kwan T, McPherson P, Nguyen HB, Rimmelé T, Shapiro NI, Shi J, Vincent JL, Chawla LS. Use of Biomarkers to Identify Acute Kidney Injury to Help Detect Sepsis in Patients With Infection. Crit Care Med 2021; 49:e360-e368. [PMID: 33566467 PMCID: PMC7963439 DOI: 10.1097/ccm.0000000000004845] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although early recognition of sepsis is vital to improving outcomes, the diagnosis may be missed or delayed in many patients. Acute kidney injury is one of the most common organ failures in patients with sepsis but may not be apparent on presentation. Novel biomarkers for acute kidney injury might improve organ failure recognition and facilitate earlier sepsis care. DESIGN Retrospective, international, Sapphire study. SETTING Academic Medical Center. PATIENTS Adults admitted to the ICU without evidence of acute kidney injury at time of enrollment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We stratified patients enrolled in the Sapphire study into three groups-those with a clinical diagnosis of sepsis (n = 216), those with infection without sepsis (n = 120), and those without infection (n = 387) at enrollment. We then examined 30-day mortality stratified by acute kidney injury within each group. Finally, we determined the operating characteristics for kidney stress markers (tissue inhibitor of metalloproteinases-2) × (insulin-like growth factor binding protein 7) for prediction of acute kidney injury as a sepsis-defining organ failure in patients with infection without a clinical diagnosis of sepsis at enrollment. Combining all groups, 30-day mortality was 23% for patients who developed stage 2-3 acute kidney injury within the first 3 days compared with 14% without stage 2-3 acute kidney injury. However, this difference was greatest in the infection without sepsis group (34% vs 11%; odds ratio, 4.09; 95% CI, 1.53-11.12; p = 0.005). Using a (tissue inhibitor of metalloproteinases-2) × (insulin-like growth factor binding protein 7) cutoff of 2.0 units, 14 patients (11.7%), in the infection/no sepsis group, tested positive of which 10 (71.4%) developed stage 2-3 acute kidney injury. The positive test result occurred a median of 19 hours (interquartile range, 0.8-34.0 hr) before acute kidney injury manifested by serum creatinine or urine output. Similar results were obtained using a cutoff of 1.0 for any stage of acute kidney injury. CONCLUSIONS Use of the urinary (tissue inhibitor of metalloproteinases-2) × (insulin-like growth factor binding protein 7) test could identify acute kidney injury in patients with infection, possibly helping to detect sepsis, nearly a day before acute kidney injury is apparent by clinical criteria.
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Affiliation(s)
- John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Antonio Artigas
- Critical Care Center, Corporacion Sanitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - Kyle J Gunnerson
- Departments of Emergency Medicine/Critical Care, Anesthesiology, Internal Medicine, Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI
| | - Patrick M Honore
- Department of Intensive Care Medicine, Brugmann University Hospital, Brussels, Belgium
| | | | - Thomas Kwan
- Astute Medical, Inc. (a bioMérieux company), San Diego, CA
| | - Paul McPherson
- Astute Medical, Inc. (a bioMérieux company), San Diego, CA
| | - H Bryant Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA
| | - Thomas Rimmelé
- Department of Anesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jing Shi
- Walker BioSciences, Carlsbad, CA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, CA
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8
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Du J, Gunnerson KJ, Bassin BS, Meldrum C, Hyzy RC. Effect of an emergency department intensive care unit on medical intensive unit admissions and care: A retrospective cohort study. Am J Emerg Med 2021; 46:27-33. [PMID: 33714051 DOI: 10.1016/j.ajem.2021.02.037] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 01/23/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Evaluate the impact of an emergency critical care center (EC3) on the admissions of critically ill patients to a critical care medicine unit (CCMU) and their outcomes. METHODS This was a retrospective before/after cohort study in a tertiary university teaching hospital. To improve the care of critically ill patients in the emergency department (ED), a 9-bed EC3 was opened in the ED in February 2015. All critically ill patients in the emergency department must receive intensive support in EC3 before being considered for admission to the CCMU for further treatment. Patients from the emergency department account for a significant proportion of the patients admitted to the CCMU. The proportions of patients admitted to the CCMU from the ED were analyzed 1 year before and 1 year after the opening of the EC3. We also compared the admission data, demographic data, APACHE III scores and patient outcomes among patients admitted from ED to the CCMU in the year before and the year after the opening of the EC3. RESULT The establishment of the EC3 was associated with a decreased proportion of patients admitted to the CCMU from the ED (OR 0.73 95% CI 0.63-0.84, p < 0.01), a decrease in the proportion of patients with sepsis admitted from the ED (OR 0.68, 95% CI, 0.54-0.87, p < 0.01) and a decrease in the proportion of patients with gastrointestinal bleeding admitted from the ED (OR 0.49, 95% CI 0.28-0.84, p < 0.05). Following the establishment of the EC3, patients admitted to the CCMU had a higher APACHE III score in 2015 (74.85 ± 30.42 vs 72.39 ± 29.64, p = 0.015). Fewer low-risk patients were admitted to the CCMU for monitoring following the opening of the EC3 (112 [6.8%] vs. 181 [9.3%], p < 0.01). Propensity score matching analysis showed that the opening of the EC3 was associated with improved 60-day survival (HR 0.84, 95% CI 0.70-0.99, p = 0.046). CONCLUSION Following the opening of the EC3, the proportion of CCMU admissions from the ED decreased. The EC3 may be most effective at reducing the admission of lower-acuity patients with GI bleeding and possibly sepsis. The EC3 may be associated with improved survival in ED patients.
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Affiliation(s)
- Jiang Du
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA; Shanghai General Hospital of Shanghai Jiaotong University, Shanghai, China
| | - Kyle J Gunnerson
- Emergency Department, The University of Michigan Health System, MI, USA
| | - Benjamin S Bassin
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA
| | - Craig Meldrum
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA
| | - Robert C Hyzy
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA.
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9
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Wieruszewski PM, Wittwer ED, Kashani KB, Brown DR, Butler SO, Clark AM, Cooper CJ, Davison DL, Gajic O, Gunnerson KJ, Tendler R, Mara KC, Barreto EF. Angiotensin II Infusion for Shock: A Multicenter Study of Postmarketing Use. Chest 2020; 159:596-605. [PMID: 32882250 DOI: 10.1016/j.chest.2020.08.2074] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/11/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vasodilatory shock refractory to catecholamine vasopressors and arginine vasopressin is highly morbid and responsible for significant mortality. Synthetic angiotensin II is a potent vasoconstrictor that may be suitable for use in these patients. RESEARCH QUESTION What is the safety and effectiveness of angiotensin II and what variables are associated with a favorable hemodynamic response? STUDY DESIGN AND METHODS We performed a multicenter, retrospective study at five tertiary medical centers in the United States. The primary end point of hemodynamic responsiveness to angiotensin II was defined as attainment of mean arterial pressure (MAP) of ≥ 65 mm Hg with a stable or reduced total vasopressor dosage 3 h after drug initiation. RESULTS Of 270 included patients, 181 (67%) demonstrated hemodynamic responsiveness to angiotensin II. Responders showed a greater increase in MAP (+10.3 mm Hg vs +1.6 mm Hg, P < .001) and reduction in vasopressor dosage (-0.20 μg/kg/min vs +0.04 μg/kg/min; P < .001) compared with nonresponders at 3 h. Variables associated with favorable hemodynamic response included lower lactate concentration (OR 1.11; 95% CI, 1.05-1.17, P < .001) and receipt of vasopressin (OR, 6.05; 95% CI, 1.98-18.6; P = .002). In severity-adjusted multivariate analysis, hemodynamic responsiveness to angiotensin II was associated with reduced likelihood of 30-day mortality (hazard ratio, 0.50; 95% CI, 0.35-0.71; P < .001). Arrhythmias occurred in 28 patients (10%) and VTE was identified in 4 patients. INTERPRETATION In postmarketing use for vasopressor-refractory shock, 67% of angiotensin II recipients demonstrated a favorable hemodynamic response. Patients with lower lactate concentrations and those receiving vasopressin were more likely to respond to angiotensin II. Patients who responded to angiotensin II experienced reduced mortality.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN
| | - Erica D Wittwer
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Daniel R Brown
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Angela M Clark
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI
| | - Craig J Cooper
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - Danielle L Davison
- Departments of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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10
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Haas NL, Puls HA, Adan AJ, Hatton C, Joseph JR, Hebert C, Hackenson D, Gunnerson KJ, Bassin BS. Emergency Department-based Intensive Care Unit Use Peaks Near Emergency Department Shift Turnover. West J Emerg Med 2020; 21:866-870. [PMID: 32726257 PMCID: PMC7390565 DOI: 10.5811/westjem.2020.4.46000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/13/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians. The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied. We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED. We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times. Methods An electronic health record search identified all patients managed in the ED and ED-ICU in 2016 and 2017. We analyzed the number of ED arrivals per hour, the number of ED-ICU consults per hour, the time interval from ED arrival to ED-ICU consult, the distribution throughout the day, and the relationship with shift turnover times in the main ED. Results A total of 160,198 ED visits were queried, of which 5308 (3.3%) were managed in the ED-ICU. ED shift turnover times were 7 am, 3 pm, and 11 pm. The mean number of ED-ICU consults placed per hour was 221 (85 standard deviation), with relative maximums occurring near ED turnover times: 10:31 pm–11:30 pm (372) and 2:31 pm–3:30 pm (365). The minimum was placed between 7:31 am – 8:30 am (88), shortly after the morning ED turnover time. The median interval from ED arrival time to ED-ICU consult order was 161 minutes (range 6–1,434; interquartile range 144–174). Relative minimums were observed for patients arriving shortly prior to ED turnover times: 4:31 am – 5:30 am (120 minutes [min]), 12:31 pm – 1:30 pm (145 min), and 9:31 pm – 10:30 pm (135 min). Relative maximums were observed for patients arriving shortly after ED turnover times: 7:31 am – 8:30 am (177 min), 4:31 pm – 5:30 pm (218 min), and 11:31 pm – 12:30 am (179 min). Conclusion ED-ICU utilization was highest near ED shift turnover times, and utilization was dissimilar to overall ED arrival patterns. Patients arriving immediately prior to ED shift turnover received earlier consults to the ED-ICU, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of emergency clinicians. These findings may guide operational planning, staffing models, and timing of shift turnover for other institutions implementing ED-ICUs. Future studies could investigate whether an ED-ICU model improves critically ill patients’ outcomes by minimizing ED provider handoffs.
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Affiliation(s)
- Nathan L Haas
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan.,Michigan Medicine, Division of Emergency Critical Care, Ann Arbor, Michigan
| | - Henrique A Puls
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Andrew J Adan
- University of Cincinnati, Department of Emergency Medicine, Cincinnati, Ohio
| | - Colman Hatton
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - John R Joseph
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Christopher Hebert
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, Washington
| | - David Hackenson
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan.,Michigan Medicine, Division of Emergency Critical Care, Ann Arbor, Michigan
| | - Kyle J Gunnerson
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan.,Michigan Medicine, Division of Emergency Critical Care, Ann Arbor, Michigan.,Michigan Medicine, Department of Internal Medicine, Ann Arbor, Michigan.,Michigan Medicine, Department of Anesthesiology/Critical Care, Ann Arbor, Michigan
| | - Benjamin S Bassin
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan.,Michigan Medicine, Division of Emergency Critical Care, Ann Arbor, Michigan
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11
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Haas NL, Whitmore SP, Cranford JA, Tsuchida RE, Nicholson A, Boyd C, Gunnerson KJ, Gianchandani RY, Bassin BS. An Emergency Department-Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis. J Emerg Med 2019; 58:620-626. [PMID: 31843318 DOI: 10.1016/j.jemermed.2019.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 06/17/2019] [Revised: 09/27/2019] [Accepted: 10/13/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED. OBJECTIVE We sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA. METHODS This was a retrospective pre-post cohort of ED visits from 2012-2018 at a single academic medical center. Adult ED patients in DKA (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 14, and glucose > 250 mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed. RESULTS We identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p < 0.001, number needed to treat [NNT] = 8) or general floor bed (58.0% vs. 73.3%, p < 0.001, NNT = 6), and more were discharged from the ED (27.1% vs. 1.4%, p < 0.001, NNT = 4). Rates of hypokalemia (10.1% vs. 6.0%, p = 0.08) and admission to non-ICU with transfer to ICU within 24 h (0.5% vs. 0%, p = 0.30) did not differ. CONCLUSION Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.
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Affiliation(s)
| | | | | | | | | | - Caryn Boyd
- University of Michigan, Ann Arbor, Michigan
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12
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Gunnerson KJ, Bassin BS, Havey RA, Haas NL, Sozener CB, Medlin RP, Gegenheimer-Holmes JA, Laurinec SL, Boyd C, Cranford JA, Whitmore SP, Hsu CH, Khan R, Vazirani NN, Maxwell SG, Neumar RW. Association of an Emergency Department-Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions. JAMA Netw Open 2019; 2:e197584. [PMID: 31339545 PMCID: PMC6659143 DOI: 10.1001/jamanetworkopen.2019.7584] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Increased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes. OBJECTIVE To determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019. EXPOSURES Implementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs. MAIN OUTCOMES AND MEASURES The main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission. RESULTS A total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217). CONCLUSIONS AND RELEVANCE Implementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.
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Affiliation(s)
- Kyle J. Gunnerson
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Benjamin S. Bassin
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
| | - Renee A. Havey
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
| | - Nathan L. Haas
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
| | - Cemal B. Sozener
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
| | - Richard P. Medlin
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | | | - Stephanie L. Laurinec
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
| | - Caryn Boyd
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - James A. Cranford
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Sage P. Whitmore
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Cindy H. Hsu
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor
| | - Reham Khan
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Neha N. Vazirani
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- School of Dentistry, University of Michigan, Ann Arbor
| | - Stephen G. Maxwell
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Robert W. Neumar
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
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Whitmore SP, Gunnerson KJ, Haft JW, Lynch WR, VanDyck T, Hebert C, Waldvogel J, Havey R, Weinberg A, Cranford JA, Rooney DM, Neumar RW. Simulation training enables emergency medicine providers to rapidly and safely initiate extracorporeal cardiopulmonary resuscitation (ECPR) in a simulated cardiac arrest scenario. Resuscitation 2019; 138:68-73. [PMID: 30862530 DOI: 10.1016/j.resuscitation.2019.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [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: 12/11/2018] [Revised: 02/23/2019] [Accepted: 03/04/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Extracorporeal cardiopulmonaryresuscitation (ECPR) is emerging as a viable rescue strategy for refractory out-of-hospital cardiac arrest. In the U.S., limited training of emergency medicine providers is a barrier to widespread implementation. AIMS Test the hypothesis that emergency medicine physicians and nurses can acquire and retain the skills to rapidly and safely initiate ECPR using high-fidelity simulation. STUDY DESIGN Prospective interventional study. SETTING U.S. tertiary academic medical center. SUBJECTS Emergency medicine physicians and nurses with no prior ECPR/ECMO experience. METHODS Teams of three physicians and three nurses underwent a two-day ECPR training course including didactics, hands-on training, and simulation. Teams were videotaped initiating ECPR in a high-fidelity simulation scenario before and after simulation training. The primary outcome was the proportion of simulations in which full ECPR support was achieved within 30 min of patient arrival. RESULTS Five teams completed the entire study. Full ECPR support was achieved within 30 min of patient arrival in 11/15, 15/15, and 15/15 attempts at baseline (B), post-testing (PT) and 3-month post-testing (3-PT), respectively (p = 0.06). Intervals (mean ± sd) required to achieve full ECPR support at B, PT, and 3-PT were 25.8±5.3, 17.2±4.6, and 19.2±1.9 min respectively (p < 0.05 for B vs. PT and 3-PT). CONCLUSION High fidelity simulation training is effective in preparing emergency medicine physicians and nurses to rapidly and safely initiate ECPR in a simulated cardiac arrest scenario, and should be considered when implementing an ED-based ECPR program.
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Affiliation(s)
- Sage P Whitmore
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Extracorporeal Life Support Program, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - William R Lynch
- Department of Surgery, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Extracorporeal Life Support Program, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Tyler VanDyck
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Christopher Hebert
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - John Waldvogel
- The Extracorporeal Life Support Program, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Renee Havey
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Allison Weinberg
- The Extracorporeal Life Support Program, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - James A Cranford
- Department of Psychiatry, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Deborah M Rooney
- Department of Learning Health Sciences, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Robert W Neumar
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA.
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Haas NL, Gianchandani RY, Gunnerson KJ, Bassin BS, Ganti A, Hapner C, Boyd C, Cranford JA, Whitmore SP. The Two-Bag Method for Treatment of Diabetic Ketoacidosis in Adults. J Emerg Med 2018; 54:593-599. [PMID: 29628184 DOI: 10.1016/j.jemermed.2018.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 08/23/2017] [Revised: 12/15/2017] [Accepted: 01/06/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The "two-bag method" of management of diabetic ketoacidosis (DKA) allows for titration of dextrose delivery by adjusting the infusions of two i.v. fluid bags of varying dextrose concentrations while keeping fluid, electrolyte, and insulin infusion rates constant. OBJECTIVE We aimed to evaluate the feasibility and potential benefits of this strategy in adult emergency department (ED) patients with DKA. METHODS This is a before-and-after comparison of a protocol using the two-bag method operationalized in our adult ED in 2015. A retrospective electronic medical record search identified adult ED patients presenting with DKA from January 1, 2013 to June 30, 2016. Clinical and laboratory data, timing of medical therapies, and safety outcomes were collected and analyzed. RESULTS Sixty-eight patients managed with the two-bag method (2B) and 107 patients managed with the one-bag method (1B) were identified. The 2B and 1B groups were similar in demographics and baseline metabolic derangements, though significantly more patients in the 2B group received care in a hybrid ED and intensive care unit setting (94.1% vs. 51.4%; p < 0.01). 2B patients experienced a shorter interval to first serum bicarbonate ≥ 18 mEq/L (13.4 vs. 20.0 h; p < 0.05), shorter duration of insulin infusion (14.1 vs. 21.8 h; p < 0.05), and fewer fluid bags were charged to the patient (5.2 vs. 29.7; p < 0.01). Frequency of any measured hypoglycemia or hypokalemia trended in favor of the 2B group (2.9% vs. 10.3%; p = 0.07; 16.2% vs. 27.1%; p = 0.09; respectively), though did not reach significance. CONCLUSIONS The 2B method appears feasible for management of adult ED patients with DKA, and use was associated with earlier correction of acidosis, earlier discontinuation of insulin infusion, and fewer i.v. fluid bags charged than traditional 1B methods, while no safety concerns were observed.
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Affiliation(s)
- Nathan L Haas
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Roma Y Gianchandani
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan; Division of Metabolism, Endocrinology and Diabetes, Michigan Medicine, Ann Arbor, Michigan
| | - Kyle J Gunnerson
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan; Division of Emergency Critical Care, Michigan Medicine, Ann Arbor, Michigan; Department of Anesthesiology/Critical Care, Michigan Medicine, Ann Arbor, Michigan
| | - Benjamin S Bassin
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; Division of Emergency Critical Care, Michigan Medicine, Ann Arbor, Michigan
| | - Arun Ganti
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Christopher Hapner
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Caryn Boyd
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - James A Cranford
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan
| | - Sage P Whitmore
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; Division of Emergency Critical Care, Michigan Medicine, Ann Arbor, Michigan; Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Michigan Medicine, Ann Arbor, Michigan
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Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF, Gunnerson KJ, Weng C, McKellar S. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation 2016; 107:38-46. [PMID: 27523953 DOI: 10.1016/j.resuscitation.2016.07.237] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/12/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.
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Affiliation(s)
- Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 3C127, Salt Lake City, UT 84132, United States; Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 1C26 SOM, Salt Lake City, UT 84132, United States.
| | - Nicholas J Johnson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA 98195-6522, United States.
| | - John Greenwood
- Department of Emergency Medicine, Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, United States.
| | - David F Gaieski
- Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, 1025 Walnut Street, 300 College Building, Philadelphia, PA 19107, United States.
| | - Zachary Shinar
- Department of Emergency Medicine, Sharpe Memorial Hospital, 7901 Frost Street, San Diego, CA 92123, United States.
| | - Joseph M Bellezo
- Department of Emergency Medicine, Emergency Department ECMO Services, Department of Emergency Medicine, Sharpe Memorial Hospital, 7901 Frost Street, San Diego, CA 92123, United States.
| | - Lance Becker
- Hofstra Northwell School of Medicine, Chairman of Emergency Medicine at Long Island Jewish Medical Center & North Shore University Hospital, 270-05 76th Ave., New Hyde Park, NY 11040, United States.
| | - Atman P Shah
- Section of Cardiology, Adult Cardiac Catheterization Laboratory, The University of Chicago, 5841 S. Maryland Avenue, MC 6080, Chicago, IL 60637, United States.
| | - Scott T Youngquist
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 1C26 SOM, Salt Lake City, UT 84132, United States; Salt Lake City Fire Department, 475 300 E, Salt Lake City, UT 84111, United States.
| | - Michael P Mallin
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 1C26 SOM, Salt Lake City, UT 84132, United States.
| | - James Franklin Fair
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 1C26 SOM, Salt Lake City, UT 84132, United States.
| | - Kyle J Gunnerson
- Departments of Emergency Medicine, Anesthesiology, and Internal Medicine, Michigan Center for Integrative Research In Critical Care (MCIRCC), University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109-5303, United States.
| | - Cindy Weng
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, United States.
| | - Stephen McKellar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, 30 North 1900 East, 3C127, Salt Lake City, UT 84132, United States.
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Mosier JM, Kelsey M, Raz Y, Gunnerson KJ, Meyer R, Hypes CD, Malo J, Whitmore SP, Spaite DW. Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions. Crit Care 2015; 19:431. [PMID: 26672979 PMCID: PMC4699333 DOI: 10.1186/s13054-015-1155-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that augments oxygenation, ventilation and/or cardiac output via cannulae connected to a circuit that pumps blood through an oxygenator and back into the patient. ECMO has been used for decades to support cardiopulmonary disease refractory to conventional therapy. While not robust, there are promising data for the use of ECMO in acute hypoxemic respiratory failure, cardiac arrest, and cardiogenic shock and the potential indications for ECMO continue to increase. This review discusses the existing literature on the potential use of ECMO in critically ill patients within the emergency department.
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Affiliation(s)
- Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA. .,Arizona Emergency Medicine Research Center, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA. .,Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA.
| | - Melissa Kelsey
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA
| | - Yuval Raz
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA
| | - Kyle J Gunnerson
- Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Robyn Meyer
- Division of Pediatric Intensive Care, Department of Pediatrics, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA
| | - Cameron D Hypes
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA.,Arizona Emergency Medicine Research Center, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA.,Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA
| | - Josh Malo
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85721, USA
| | - Sage P Whitmore
- Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, University of Arizona, 1609 N. Warren Ave, Tucson, AZ, 85724, USA
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Ginde AA, Blatchford PJ, Trzeciak S, Hollander JE, Birkhahn R, Otero R, Osborn TM, Moretti E, Nguyen HB, Gunnerson KJ, Milzman D, Gaieski DF, Goyal M, Cairns CB, Rivers EP, Shapiro NI. Age-related differences in biomarkers of acute inflammation during hospitalization for sepsis. Shock 2015; 42:99-107. [PMID: 24978893 DOI: 10.1097/shk.0000000000000182] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors aimed to evaluate age-related differences in inflammation biomarkers during the first 72 h of hospitalization for sepsis. This was a secondary analysis of a prospective observational cohort of adult patients (n = 855) from 10 urban academic emergency departments with confirmed infection and two or more systemic inflammatory response syndrome criteria. Six inflammation-related biomarkers were analyzed-chemokine (CC-motif) ligand-23, C-reactive protein, interleukin-1 receptor antagonist, neutrophil gelatinase-associated lipocalin (NGAL), peptidoglycan recognition protein, and tumor necrosis factor receptor-1a (TNFR-1a)-measured at presentation and 3, 6, 12, 24, 48, or 72 h later. The median age was 56 (interquartile range, 43 - 72) years, and sepsis severity was 38% sepsis, 16% severe sepsis without shock, and 46% septic shock; the overall 30-day mortality was 12%. Older age was associated with higher sepsis severity: 41% of subjects aged 18 to 34 years had severe sepsis or septic shock compared with 71% for those aged 65 years or older (P < 0.001). In longitudinal models adjusting for demographics, comorbidities, and infection source, older age was associated with higher baseline values for chemokine (CC-motif) ligand-23, interleukin-1 receptor antagonist, NGAL, and TNFR-1a (all P < 0.05). However, older adults had higher mean values during the entire 72-h period only for NGAL and TNFR-1a and higher final 72-h values only for TNFR-1a. Adjustment or stratification by sepsis severity did not change the age-inflammation associations. Although older adults had higher levels of inflammation at presentation and an increased incidence of severe sepsis and septic shock, these age-related differences in inflammation largely resolved during the first 72 h of hospitalization.
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Affiliation(s)
- Adit A Ginde
- *Department of Emergency Medicine, University of Colorado School of Medicine; and †Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado; ‡Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, New Jersey; §Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ∥New York Methodist Hospital, Brooklyn; and Weill Cornell Medical Center, New York, New York; ¶Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; **Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; ††Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; ‡‡Departments of Emergency Medicine and Medicine, Loma Linda University Medical Center, Loma Linda, California; §§Departments of Anesthesiology and Internal Medicine, University of Michigan, Ann Arbor, Michigan; ∥∥Departments of Emergency Medicine, and ¶¶Internal Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, District of Columbia; ***Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina; †††Department of Emergency Medicine, Wayne State University, Detroit, Michigan; and ‡‡‡Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Kashani K, Al-Khafaji A, Ardiles T, Artigas A, Bagshaw SM, Bell M, Bihorac A, Birkhahn R, Cely CM, Chawla LS, Davison DL, Feldkamp T, Forni LG, Gong MN, Gunnerson KJ, Haase M, Hackett J, Honore PM, Hoste EAJ, Joannes-Boyau O, Joannidis M, Kim P, Koyner JL, Laskowitz DT, Lissauer ME, Marx G, McCullough PA, Mullaney S, Ostermann M, Rimmelé T, Shapiro NI, Shaw AD, Shi J, Sprague AM, Vincent JL, Vinsonneau C, Wagner L, Walker MG, Wilkerson RG, Zacharowski K, Kellum JA. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care 2013; 17:R25. [PMID: 23388612 PMCID: PMC4057242 DOI: 10.1186/cc12503] [Citation(s) in RCA: 814] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 01/12/2013] [Accepted: 01/16/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) can evolve quickly and clinical measures of function often fail to detect AKI at a time when interventions are likely to provide benefit. Identifying early markers of kidney damage has been difficult due to the complex nature of human AKI, in which multiple etiologies exist. The objective of this study was to identify and validate novel biomarkers of AKI. METHODS We performed two multicenter observational studies in critically ill patients at risk for AKI - discovery and validation. The top two markers from discovery were validated in a second study (Sapphire) and compared to a number of previously described biomarkers. In the discovery phase, we enrolled 522 adults in three distinct cohorts including patients with sepsis, shock, major surgery, and trauma and examined over 300 markers. In the Sapphire validation study, we enrolled 744 adult subjects with critical illness and without evidence of AKI at enrollment; the final analysis cohort was a heterogeneous sample of 728 critically ill patients. The primary endpoint was moderate to severe AKI (KDIGO stage 2 to 3) within 12 hours of sample collection. RESULTS Moderate to severe AKI occurred in 14% of Sapphire subjects. The two top biomarkers from discovery were validated. Urine insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP-2), both inducers of G1 cell cycle arrest, a key mechanism implicated in AKI, together demonstrated an AUC of 0.80 (0.76 and 0.79 alone). Urine [TIMP-2]·[IGFBP7] was significantly superior to all previously described markers of AKI (P <0.002), none of which achieved an AUC >0.72. Furthermore, [TIMP-2]·[IGFBP7] significantly improved risk stratification when added to a nine-variable clinical model when analyzed using Cox proportional hazards model, generalized estimating equation, integrated discrimination improvement or net reclassification improvement. Finally, in sensitivity analyses [TIMP-2]·[IGFBP7] remained significant and superior to all other markers regardless of changes in reference creatinine method. CONCLUSIONS Two novel markers for AKI have been identified and validated in independent multicenter cohorts. Both markers are superior to existing markers, provide additional information over clinical variables and add mechanistic insight into AKI. TRIAL REGISTRATION ClinicalTrials.gov number NCT01209169.
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Affiliation(s)
- Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15213, USA
| | - Thomas Ardiles
- Department of Critical Care, Maricopa Integrated Health System, 2601 E Roosevelt Street, Phoenix, AZ 85008, USA
| | - Antonio Artigas
- Critical Care Center, Sabadell Hospital, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Parc Tauli s/n, Sabadell, Barcelona 8208, Spain
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 3C1.12 Walter C. Mackenzie Centre, 8440 112 Street NW, Edmonton, Alberta T6G 2B7, Canada
| | - Max Bell
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital, Karolinskavagen, Solna, Stockholm SE-171 76, Sweden
| | - Azra Bihorac
- Department of Anesthesiology, University of Florida, 1660 SW Archer Road, Gainesville, FL 32611, USA
| | - Robert Birkhahn
- Department of Emergency Medicine, New York Methodist Hospital, 506 6th Street, Brooklyn, NY 11215, USA
| | - Cynthia M Cely
- Bruce W. Carter Department of Veterans Affairs Medical Center, 1201 NW 16th Street, Miami, FL 33125, USA
| | - Lakhmir S Chawla
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, 900 23rd Street NW, Washington, DC 20037, USA
| | - Danielle L Davison
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, 900 23rd Street NW, Washington, DC 20037, USA
| | - Thorsten Feldkamp
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, Essen, 45147, Germany
| | - Lui G Forni
- Intensive Care Medicine, Western Sussex Hospitals Trust, Lyndhurst Road, Worthing, West Sussex, BN11 2DH, UK
| | - Michelle Ng Gong
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Kyle J Gunnerson
- Departments of Anesthesiology and Emergency Medicine, Virginia Commonwealth University Medical Center, 1200 East Broad Street, Richmond, VA 23298, USA
| | - Michael Haase
- Department of Nephrology, Otto-von-Guericke-Universitat Magdeburg, Leipziger Strasse 44, Magdeburg, 39120, Germany
| | - James Hackett
- Hackett & Associates, Inc., 14419 Rancho Del Prado Trail, San Diego, CA 92127, USA
| | - Patrick M Honore
- ICU Department, Universitair Ziekenhuis Brussel (UZB), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, Brussels 1090, Belgium
| | - Eric AJ Hoste
- Intensive Care Unit, Ghent University Hospital, De Pintelaan 185, Ghent, 9000, Belgium
| | - Olivier Joannes-Boyau
- Anaesthesiology and Critical Care Department 2, University Hospital of Bordeaux, 1 Avenue De Magellon, Pessac, 33600, France
| | - Michael Joannidis
- Department of Internal Medicine, ICU, Medical University Innsbruck, Anichstrasse 35, Innsbruck, A-6020, Austria
| | - Patrick Kim
- Traumatology, Surgical Critical Care and Emergency Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jay L Koyner
- Department of Medicine, University of Chicago, 6030 South Ellis Avenue, Chicago, IL 60637, USA
| | - Daniel T Laskowitz
- Department of Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Matthew E Lissauer
- Department of Surgery, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Gernot Marx
- Department of Intensive Care, Universitätsklinikum der RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany
| | - Peter A McCullough
- Department of Medicine, St John Providence Health System, Providence Hospitals and Medical Centers, Providence Park Heart Institute, 47601 Grand River Avenue, Novi, MI 48374, USA
| | - Scott Mullaney
- Department of Medicine, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92103, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Thomas Rimmelé
- Service D'Anesthésie Réanimation, Edouard Herriot Hospital, Hospices civils de Lyon, 5 Place d'Arsonval, Lyon, 69003, France
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA 2215, USA
| | - Andrew D Shaw
- Department of Anesthesia, Duke University Medical Center/Durham Veterans Affairs Medical Center, 508 Fulton Street, Durham, NC 27705, USA
| | - Jing Shi
- Walker Biosciences, 6321 Allston Street, Carlsbad, CA 92009, USA
| | - Amy M Sprague
- Department of Medicine, Joseph M. Still Research Foundation, 3675 J. Dewey Gray Circle, Augusta, GA 30909, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Route De Lennik 808, Brussels, 1070, Belgium
| | - Christophe Vinsonneau
- Department of Intensive Care, Hospital Marc Jacquet, 2 Rue Freteau De Peny, Melun, 77011, France
| | - Ludwig Wagner
- Department of Internal Medicine, Medical University of Vienna, Spitalgasse 23, Vienna 1090, Austria
| | - Michael G Walker
- Walker Biosciences, 6321 Allston Street, Carlsbad, CA 92009, USA
| | - R Gentry Wilkerson
- Department of Emergency Medicine, Tampa General Hospital, 1 Davis Boulevard, Tampa, FL 33606, USA
| | - Kai Zacharowski
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15213, USA
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Gunnerson KJ. Antecedent bradycardia: An opportunity for pre-arrest intervention? Resuscitation 2012; 83:1053-4. [DOI: 10.1016/j.resuscitation.2012.06.008] [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] [Received: 06/01/2012] [Accepted: 06/06/2012] [Indexed: 10/28/2022]
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Shah KB, Tang DG, Kasirajan V, Gunnerson KJ, Hess ML, Sica DA. Impact of low-dose B-type natriuretic peptide infusion on urine output after total artificial heart implantation. J Heart Lung Transplant 2012; 31:670-2. [PMID: 22425232 DOI: 10.1016/j.healun.2012.02.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 02/03/2012] [Accepted: 02/11/2012] [Indexed: 11/15/2022] Open
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Perman SM, Chang AM, Hollander JE, Gaieski DF, Trzeciak S, Birkhahn R, Otero R, Osborn TM, Moretti E, Nguyen HB, Gunnerson KJ, Milzman D, Goyal M, Cairns CB, Ngo L, Rivers EP, Shapiro NI. Relationship between B-type natriuretic peptide and adverse outcome in patients with clinical evidence of sepsis presenting to the emergency department. Acad Emerg Med 2011; 18:219-22. [PMID: 21314784 DOI: 10.1111/j.1553-2712.2010.00968.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [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: 12/16/2022]
Abstract
OBJECTIVES Myocardial dysfunction is an important aspect of sepsis pathophysiology. B-type natriuretic peptide (BNP) is a neurohormone released from the ventricles in response to myocardial stretch and volume overload. The authors hypothesized that an elevated BNP in patients presenting to the emergency department (ED) with suspected sepsis are at increased risk for development of adverse events. METHODS This was a prospective, observational, multicenter cohort study in 10 EDs. Patients were eligible if they were older than 18 years, had two or more systemic inflammatory response syndrome (SIRS) criteria, and had suspected infection or a serum lactate level > 2.5 mmol/L. Patients were excluded if they were pregnant, had do-not-attempt-resuscitation status, sustained a cardiac arrest prior to hospital arrival, had known chronic renal insufficiency, or were on dialysis. BNP levels were obtained at arrival. The primary outcome was a composite of severe sepsis, septic shock within 72 hours, or in-hospital mortality. RESULTS There were 825 patients enrolled (mean ± standard deviation [SD] age = 53.5 ± 19.6 years; 51% were female and 37% were African American). The area under the curve (AUC) for BNP to predict the triple composite outcome was 0.69, and the optimal cut-point of BNP was 49 pg/mL. Patients with a BNP > 49 pg/mL had a greater mortality rate (11.6% vs. 2.1%; p = 0.0001), a greater risk of development of severe sepsis (67.7% vs. 36.8%; p = 0.0001) and septic shock (51.7% vs. 26.4%; p = 0.0001), and a higher rate of the triple composite outcome (69% vs. 37%; unadjusted odds ratio [OR] = 1.9, 95% confidence interval [CI] = 1.6 to 2.1; p < 0.001). The sensitivity was 63% (95% CI = 58% to 67%), specificity was 69% (95% CI = 65% to 73%), negative predictive value (NPV) was 63% (95% CI = 58% to 67%), and positive predictive value (PPV) was 69% (95% CI = 65% to 74%). In multivariate modeling, after adjusting for age, sex, heart rate, white blood cell count, and creatinine, an elevated BNP was associated with increased odds of having the composite outcome. The outcome was similar in the subset of patients who did not have severe sepsis or septic shock upon arrival. CONCLUSIONS In patients who present to the ED with SIRS criteria and suspected infection, an elevated BNP is associated with a worse prognosis but has limited diagnostic utility.
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Abstract
OBJECTIVES Critical care medicine (CCM) is of growing interest among emergency physicians (EPs), but the number of CCM-trained EPs and their postfellowship practice is unknown. This study's purpose was to conduct a descriptive census survey of EPs who have completed or are currently in a CCM fellowship. METHODS The authors created a Web-based survey, and requests to participate were sent to EPs who have completed or are currently in a CCM fellowship. Responses were collected over a 12-month period. Physicians were located via multiple whom electronic mailing lists, including the Emergency Medicine Section of the Society of Critical Care Medicine, Critical Care Section of the American College of Emergency Physicians, and the Emergency Medicine Residents' Association. The authors also contacted CCM fellowship coordinators and used informal networking. Data were collected on emergency medicine (EM) and other residency training; discipline, duration, and year of CCM fellowship; current practice setting; and board certification status, including the European Diploma in Intensive Care (EDIC). RESULTS A total of 104 physicians completed the survey (97% response rate), of whom 73 had completed fellowship at the time of participation, and 31 of whom were in fellowship training. Of those who completed fellowship, 36/73 (49%) practice both EM and CCM, and 45/73 (62%) practice in academic institutions. Multiple disciplines of fellowship were represented: multidisciplinary (39), surgical (28), internal medicine (16), anesthesia (14), and other (4). Together, the CCM fellowships at the University of Maryland R Adams Cowley Shock Trauma Center and the University of Pittsburgh have trained 42% of all EM-CCM physicians, with 38 other institutions training from one to four fellows each. The number of EPs completing CCM fellowships has risen: from 1974 to 1989, 12 EPs; from 1990 to 1999, 15 EPs; and from 2000 to 2007, 43 EPs. CONCLUSIONS Emergency physicians are entering CCM fellowships in increasing numbers. Almost half of these EPs practice both EM and CCM.
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Affiliation(s)
- Julie A Mayglothling
- Department of Emergency Medicine, Virginia Commonwealth University Reanimation, Engineering and Shock Center, Virginia Commonwealth University, Richmond, VA, USA.
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Ensor CR, Cahoon WD, Crouch MA, Katlaps GJ, Hess ML, Cooke RH, Gunnerson KJ, Kasirajan V. Antithrombotic therapy for the CardioWest temporary total artificial heart. Tex Heart Inst J 2010; 37:149-158. [PMID: 20401285 PMCID: PMC2851409] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The CardioWest temporary total artificial heart serves as a viable bridge to orthotopic heart transplantation in patients who are experiencing end-stage refractory biventricular heart failure. This device is associated with a low, albeit still substantial, risk of thrombosis. Platelet interactions with artificial surfaces are complex and result in continuous activation of contact proteins despite therapeutic anticoagulation. We searched the medical literature (publication dates, January 1962-October 2009) in order to evaluate means of mitigating adverse events that have occurred after implantation of the CardioWest temporary total artificial heart.We conclude that the use of a multitargeted antithrombotic approach, involving anticoagulation (bivalirudin and warfarin) and antiplatelet therapy (dipyridamole and aspirin), can mitigate the procoagulative effects of mechanical circulatory assist devices, particularly those that are associated with the CardioWest temporary total artificial heart. Careful monitoring with use of a variant multisystem approach, involving efficacy tests (thrombelastography and light transmittance aggregometry), safety tests (laboratory analyses), and warfarin genomics, may maximize the therapeutic actions and minimize the bleeding risks that are associated with the multitargeted antithrombotic approach. The development and monitoring of individualized antithrombotic regimens require that informed health professionals appreciate the complexities and grasp the hazards that are associated with these therapies.
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Affiliation(s)
- Christopher R Ensor
- Department of Pharmacy, Comprehensive Transplant Center, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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Crouch MA, Kasirajan V, Cahoon W, Katlaps GJ, Gunnerson KJ. Successful Use and Dosing of Bivalirudin After Temporary Total Artificial Heart Implantation: A Case Series. Pharmacotherapy 2008; 28:1413-20. [DOI: 10.1592/phco.28.11.1413] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Gunnerson KJ, Brant S, Greenfield N, Reynolds PS, Aro T, Yee A, Ornato JP, Ward KR. PRE-HOSPITAL POINT OF CARE LACTATE DOES NOT CORRELATE WITH INITIAL HEMODYNAMIC VARIABLES. Chest 2008. [DOI: 10.1378/chest.134.4_meetingabstracts.p65003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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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27
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Abstract
STUDY OBJECTIVE To determine if animals with abnormally low albumin levels are more susceptible to the effects of hypercapnia on BP compared to normal animals. DESIGN Prospective, controlled laboratory experiment. SETTING University research laboratory. ANIMALS Eighteen male Sprague-Dawley rats: 6 rats 10 to 12 weeks old (young Sprague-Dawley [YSD]), 6 rats 6 to 9 months old (old Sprague-Dawley [OSD]), and 6 rats 10 to 12 weeks old (Nagase analbuminemic mutant Sprague-Dawley [NAR]). METHODS Under general anesthesia and paralysis, we varied the Paco(2) by changing the respiratory rate on mechanical ventilation. Mean arterial pressure (MAP) was monitored in a continuous fashion. We obtained arterial blood for blood gas and electrolyte analysis, and nitric oxide (NO) production. RESULTS OSD rats had reduced serum albumin, while NAR rats were analbuminemic. Although NAR animals had a decreased buffer capacity compared to age-matched control animals (0.010 vs 0.013, p < 0.05), the MAP decreased in an identical fashion in all three groups. NO production increased with hypercapnia but was similar in all three groups. However, NAR rats had consistently higher plasma strong ion gap (2.8 to 4.1 mEq/L greater) compared to either YSD or OSD rats (p < 0.01), and baseline strong ion difference (mean +/- SD) was significantly lower in NAR rats (28.7 +/- 2.1 mEq/L) compared to either YSD rats (33.0 +/- 5.1 mEq/L) or OSD rats (31.2 +/- 5.1 mEq/L) [p < 0.05]. CONCLUSIONS These findings suggest that analbuminemic or hypoalbuminemic rats are not more susceptible to hypercapnia-induced hemodynamic instability. Baseline values for apparent strong ion difference are lower in NA rats consistent with a reduced buffer base resulting from analbuminemia.
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Affiliation(s)
- Jose L Gómez
- MANTRA Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Otero RM, Nguyen HB, Huang DT, Gaieski DF, Goyal M, Gunnerson KJ, Trzeciak S, Sherwin R, Holthaus CV, Osborn T, Rivers EP. Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings. Chest 2006; 130:1579-95. [PMID: 17099041 DOI: 10.1378/chest.130.5.1579] [Citation(s) in RCA: 222] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Studies of acute myocardial infarction, trauma, and stroke have been translated into improved outcomes by earlier diagnosis and application of therapy at the most proximal stage of hospital presentation. Most therapies for these diseases are instituted prior to admission to an ICU; this approach to the sepsis patient has been lacking. In response, a trial comparing early goal-directed therapy (EGDT) vs standard care was performed using specific criteria for the early identification of high-risk sepsis patients, verified definitions, and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression, and increased metabolic demands. Five years after the EGDT publication, there has been much discussion generated with regard to the concepts of EGDT, as well as debate fueled regarding diagnostic and therapeutic interventions. However, during this time period further investigations by the primary investigators and others have brought additional contemporary findings. EGDT modulates some of the components of inflammation, as reflected by improved organ function. The end points used in the EGDT protocol, the outcome results, and the cost-effectiveness have subsequently been externally validated, revealing similar or even better findings than those from the original trial. Although EGDT is faced with challenges, a coordinated approach to sepsis management is necessary to duplicate the progress in outcomes seen in patients with conditions such as acute myocardial infarction, stroke, and trauma.
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Affiliation(s)
- Ronny M Otero
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA.
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Gunnerson KJ, Saul M, He S, Kellum JA. Lactate versus non-lactate metabolic acidosis: a retrospective outcome evaluation of critically ill patients. Crit Care 2006; 10:R22. [PMID: 16507145 PMCID: PMC1550830 DOI: 10.1186/cc3987] [Citation(s) in RCA: 207] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Revised: 01/03/2006] [Accepted: 01/10/2006] [Indexed: 02/07/2023]
Abstract
Introduction Acid–base abnormalities are common in the intensive care unit (ICU). Differences in outcome exist between respiratory and metabolic acidosis in similar pH ranges. Some forms of metabolic acidosis (for example, lactate) seem to have worse outcomes than others (for example, chloride). The relative incidence of each type of disorder is unknown. We therefore designed this study to determine the nature and clinical significance of metabolic acidosis in critically ill patients. Methods An observational, cohort study of critically ill patients was performed in a tertiary care hospital. Critically ill patients were selected on the clinical suspicion of the presence of lactic acidosis. The inpatient mortality of the entire group was 14%, with a length of stay in hospital of 12 days and a length of stay in the ICU of 5.8 days. Results We reviewed records of 9,799 patients admitted to the ICUs at our institution between 1 January 2001 and 30 June 2002. We selected a cohort in which clinicians caring for patients ordered a measurement of arterial lactate level. We excluded patients in which any necessary variable required to characterize an acid–base disorder was absent. A total of 851 patients (9% of ICU admissions) met our criteria. Of these, 548 patients (64%) had a metabolic acidosis (standard base excess < -2 mEq/l) and these patients had a 45% mortality, compared with 25% for those with no metabolic acidosis (p < 0.001). We then subclassified metabolic acidosis cases on the basis of the predominant anion present (lactate, chloride, or all other anions). The mortality rate was highest for lactic acidosis (56%); for strong ion gap (SIG) acidosis it was 39% and for hyperchloremic acidosis 29% (p < 0.001). A stepwise logistic regression model identified serum lactate, SIG, phosphate, and age as independent predictors of mortality. Conclusion In critically ill patients in which a measurement of lactate level was ordered, lactate and SIG were strong independent predictors of mortality when they were the major source of metabolic acidosis. Overall, patients with metabolic acidosis were nearly twice as likely to die as patients without metabolic acidosis.
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Affiliation(s)
- Kyle J Gunnerson
- Assistant Professor, VCURES (Virginia Commonwealth University Reanimation Engineering Shock Center) Laboratory, Departments of Anesthesiology/Critical Care and Emergency Medicine, Medical College of Virginia/Virginia Commonwealth University, 1200 East Broad Street, Richmond, VA, 23298, USA
| | - Melissa Saul
- Director, Clinical Research Informatics Service, University of Pittsburgh, 450 Scaife Hall, 200 Lothrop St. Pittsburgh, PA, 15213, USA
| | - Shui He
- Research Assistant, Department of Biostatistics, University of Pittsburgh, Graduate School of Public Health, Crabtree Hall, Pittsburgh, PA, 15213, USA
| | - John A Kellum
- Professor, CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute illness) Laboratory, Department of Critical Care Medicine, University of Pittsburgh, 608, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Abstract
Acid-base abnormalities are common in critically ill patients. Our ability to describe acid-base disorders must be precise. Small differences in corrections for anion gap, different types of analytical processes, and the basic approach used to diagnose acid-base aberrations can lead to markedly different interpretations and treatment strategies for the same disorder. By applying a quantitive acid-base approach, clinicians are able to account for small changes in ion distribution that may have gone unrecognized with traditional techniques of acid-base analysis. Outcome prediction based on the quantitative approach remains controversial. This is in part due to use of various technologies to measure acid-base variables, administration of fluid or medication that can alter acid-base results, and lack of standardized nomenclature. Without controlling for these factors it is difficult to appreciate the full effect that acid-base disorders have on patient outcomes, ultimately making results of outcome studies hard to compare.
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Affiliation(s)
- Kyle J Gunnerson
- The Virginia Commonwealth University Reanimation Engineering and Shock Center (VCURES) Laboratory, Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA.
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Huang DT, Osborn TM, Gunnerson KJ, Gunn SR, Trzeciak S, Kimball E, Fink MP, Angus DC, Dellinger RP, Rivers EP. Critical Care Medicine Training and Certification for Emergency Physicians. Ann Emerg Med 2005; 46:217-23. [PMID: 16126127 DOI: 10.1016/j.annemergmed.2005.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [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: 04/12/2005] [Revised: 04/14/2005] [Accepted: 04/14/2005] [Indexed: 11/18/2022]
Abstract
Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Critical care is a continuum that includes out-of-hospital, emergency department (ED), and ICU care teams. Both emergency medicine and critical care medicine require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of critical care medicine fellowships do not accept emergency medicine residents, and those who do successfully complete a fellowship do not have access to a US certification examination in critical care medicine. Despite these barriers, interest in critical care medicine training among emergency physicians is increasing. Dual emergency medicine- and critical care medicine-trained physicians will not only help alleviate the intensivist shortage but also strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to critical care medicine certification for emergency physicians who complete a critical care fellowship.
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Affiliation(s)
- David T Huang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Huang DT, Osborn TM, Gunnerson KJ, Gunn SR, Trzeciak S, Kimball E, Fink MP, Angus DC, Dellinger RP, Rivers EP. Critical care medicine training and certification for emergency physicians*. Crit Care Med 2005; 33:2104-9. [PMID: 16148486 DOI: 10.1097/01.ccm.0000173412.43562.b3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [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: 11/26/2022]
Abstract
Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine (EM) and critical care medicine (CCM). Critical care is a continuum that includes prehospital, emergency department (ED), and intensive care unit (ICU) care teams. Both EM and CCM require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of CCM fellowships do not accept EM residents, and those who successfully complete a fellowship do not have access to a U.S. certification exam in CCM. Despite these barriers, interest in CCM training among EM physicians is increasing. Dual EM/CCM-trained physicians not only will help alleviate the intensivist shortage but also will strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to CCM certification for emergency physicians who complete a critical care fellowship.
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Affiliation(s)
- David T Huang
- The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
PURPOSE OF REVIEW Disorders of acid-base and electrolytes are commonly seen in critically ill patients. The presence of these disorders typically signals the development of an underlying pathology. These disturbances can be severe and are often associated with worse outcome. Indeed, metabolic acidosis is one of the ways we quantify organ failure. Although acid-base and electrolyte disorders may be a result of the underlying pathophysiology (eg, renal failure, respiratory failure, shock), they may also result from the way in which we manage critically ill patients. RECENT FINDINGS The application of the physical-chemical approach to acid-base analysis has led to recent developments in the identification and quantification and understanding of mechanisms for acid-base disorders commonly found in critically ill patients. Examples include a better understanding of the role of electrolytes (especially sodium and chloride) and weak acids in the pathophysiology of acid-base disorders, the implication of acid-base derangements on the inflammatory process and organ perfusion, and the importance of resuscitation fluid composition. SUMMARY By adopting a physical-chemical approach to acid-base analysis we are gaining insight to the complexities of acid-base disorders and how their treatments may affect outcome.
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Affiliation(s)
- Kyle J Gunnerson
- Virginia Commonwealth University Reanimation Engineering Shock Center, Department of Anesthesiology, Virginia Commonwealth University/Medical College of Virginia, Richmond, Virginia, USA
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Gunn SR, Rogers PL, Fink MP, Grenvik A, Gunnerson KJ, Huang D. Critical care training for emergency physicians. Ann Emerg Med 2003; 41:886-7; author reply 887. [PMID: 12790121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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35
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Gunn SR, Rogers PL, Fink MP, Grenvik A, Gunnerson KJ, Huang D. Critical care training for emergency physicians. Ann Emerg Med 2003. [DOI: 10.1067/mem.2003.223] [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: 11/22/2022]
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Affiliation(s)
- KJ Gunnerson
- CRISMA Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15261, USA
| | - M Saul
- CRISMA Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15261, USA
| | - JA Kellum
- CRISMA Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15261, USA
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