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Chaisson NF. Are Critical Care Fellowship Programs Addressing the ICU Physician Shortage? ATS Sch 2023; 4:1-3. [PMID: 37089684 PMCID: PMC10117414 DOI: 10.34197/ats-scholar.2022-0133ed] [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: 04/03/2023] Open
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Abstract
Critically ill patients are at an increased risk for developing stress ulcers of the mucosa of the upper gastrointestinal (GI) tract. Bleeding from stress ulcers was previously associated with a longer stay in the intensive care unit and an increased risk of death. Thus, most patients admitted to the intensive care unit receive stress ulcer prophylaxis. However, there is a growing concern that acid-suppression drugs may be associated with increased frequency of nosocomial pneumonia and Clostridioides difficile infection. In this article, the authors address controversies regarding stress ulcer prophylaxis in critically ill patients and provide guidance for its appropriate use in this setting.
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Affiliation(s)
- Mariam Saeed
- Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Stephanie Bass
- Medical ICU Clinical Pharmacist, Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Neal F Chaisson
- Department of Pulmonary Medicine and Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
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Samhouri BF, Mehra R, Chaisson NF. Response to "Sleep apnea and pulmonary hypertension: connecting the dots". J Clin Sleep Med 2021; 17:349-350. [PMID: 33118929 DOI: 10.5664/jcsm.8950] [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: 11/13/2022]
Affiliation(s)
- Bilal F Samhouri
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Reena Mehra
- Sleep Disorders Center, Neurologic Institute, Respiratory Institute, Heart and Vascular Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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Samhouri B, Venkatasaburamini M, Paz Y Mar H, Li M, Mehra R, Chaisson NF. Pulmonary artery hemodynamics are associated with duration of nocturnal desaturation but not apnea-hypopnea index. J Clin Sleep Med 2021; 16:1231-1239. [PMID: 32267224 DOI: 10.5664/jcsm.8468] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVES Sleep-disordered breathing and nocturnal hypoxia are prevalent among patients with precapillary pulmonary hypertension (PAH). The rationale for these associations remains unclear and these relationships have not been well studied in other forms of pulmonary hypertension (PH). We hypothesized that severity of sleep-disordered breathing and nocturnal hypoxia are associated with worsening pulmonary hemodynamics, regardless of hemodynamic profile. METHODS Four hundred ninety-three patients were divided into 4 groups: 1) no PH, 2) postcapillary pulmonary hypertension, 3) PAH, and 4) mixed PAH/postcapillary pulmonary hypertension. The relationship between right heart catheterization measurements and apnea-hypopnea index or the percentage of sleep time spent with oxygen saturation < 90% (T90) was calculated using multiple linear regression. Analysis of variance was used for between-group comparisons. Statistical models were adjusted for known confounders. RESULTS Apnea-hypopnea index did not differ between hemodynamic subgroups (P = .27) and was not associated with right atrial pressure (.11 ± .19, P = .55), cardiac index (.25 ± 1.64, P = .88), mean pulmonary artery pressure (-.004 ± .09, P = .97), or pulmonary artery occlusion pressure (.16 ± .14, P = .26). While patients with PH had a higher T90 than those without (mean 24.2% vs 11.7%, P < .001), there was no difference in T90 between individual PH subgroups (P = .70). T90 was associated with mean pulmonary artery pressure (.55 ± .10, P < .0001), PVR (1.61 ± .49, P = .001), and right atrial pressure (.50 ± .20, P = .01), but not cardiac index (-.76 ± 1.73, P = .66), or pulmonary artery occlusion pressure (.23 ± .15, P = .13). CONCLUSIONS Increased PH severity was associated with longer duration of nocturnal hypoxia regardless of hemodynamic subgroup.
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Affiliation(s)
| | | | - Hugo Paz Y Mar
- Pulmonary, Critical Care and Sleep Medicine Division, MetroHealth Medical Center, Cleveland, Ohio
| | - Manshi Li
- Department of Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Reena Mehra
- Sleep Disorders Center, Neurologic Institute, Respiratory Institute, Heart and Vascular Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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Khan NA, Ahuja KA, Wang X, Chaisson NF. Evaluation of hemodynamic parameters among patients with myeloproliferative neoplasms and suspected pulmonary hypertension. Leuk Lymphoma 2021; 62:1458-1465. [PMID: 33494630 DOI: 10.1080/10428194.2020.1864351] [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] [Indexed: 10/22/2022]
Abstract
Myeloproliferative neoplasms (MPNs) are associated with pulmonary hypertension (PH). We studied MPN patients who underwent right-heart-catheterization (RHC) to identify hemodynamic differences between MPN-subtypes. Per RHC, hemodynamics were classified as pre, post or combined pre and post-capillary PH. One-way analysis-of-variance (ANOVA) was used to compare hemodynamic differences among MPN-subtypes. Correlation of RVSP between trans-thoracic echocardiography (TTE) and RHC was evaluated. We included 68 patients. Median age was 63. Fifty-nine percent were male and 87% Caucasian. Polycythemia vera and essential thrombocythemia were the most common subtypes. On TTE, 91.5% had PH. On RHC, only 29% met criteria for pre-capillary PH. No MPN-subtype was more likely than others to have pre-capillary PH. Bland-Altman analysis showed significant intra-person variability between TTE and RHC-derived right ventricular systolic pressures. Post-capillary involvement is more common than precapillary PH in MPN. Type of PH does not appear to differ by MPN-subtype.
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Affiliation(s)
- Nauman A Khan
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Neal F Chaisson
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Khan NA, Khan RA, Tonelli AR, Highland KB, Chaisson NF, Jacob M, Renapurkar R, Dweik RA, Heresi GA. Pulmonary Edema Following Initiation of Parenteral Prostacyclin Therapy for Pulmonary Arterial Hypertension: A Retrospective Study. Chest 2019; 156:45-52. [PMID: 30776364 DOI: 10.1016/j.chest.2019.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 08/07/2018] [Revised: 01/27/2019] [Accepted: 02/01/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Pulmonary edema may complicate the use of pulmonary arterial hypertension (PAH)-targeted therapies. We aimed to determine the proportion of patients who develop pulmonary edema after initiation of parenteral prostacyclin therapy, to identify its risk factors, and to assess its implications for hospital length of stay and mortality. METHODS A retrospective cohort study of patients with PAH at the initiation of parenteral prostacyclin between 1997 and 2015 enrolled in the Cleveland Clinic PAH registry. Pulmonary edema was defined as at least one symptom or clinical sign and radiographic evidence of pulmonary edema. We determined patient characteristics predictive of pulmonary edema as well as the association between pulmonary edema and hospital length of stay (LOS) and 6-month mortality. RESULTS One hundred and fifty-five patients were included (median age, 51 years; female, 72%; white, 85%; idiopathic, 64%; and connective tissue disease [CTD], 23%). Pulmonary edema developed in 33 of 155 patients (21%). Independent predictors of pulmonary edema were high right atrial pressure (RAP), CTD etiology, and the presence of three or more risk factors for left heart disease (LHD). Pulmonary edema was associated with a 4.5-day increase in hospital LOS (95% CI, 1.4-7.5 days; P < .001) and a 4-fold increase in 6-month mortality (OR, 4.3; 95% CI, 1.28-14.36; P = .031). CONCLUSIONS Pulmonary edema occurred in 21% of patients with PAH initiated on parenteral prostacyclin. Three or more risk factors for LHD, CTD-PAH, and a high baseline RAP were independent predictors of pulmonary edema. Pulmonary edema was associated with a prolonged hospital LOS and increased 6-month mortality.
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Affiliation(s)
- Nauman A Khan
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Rizwan A Khan
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Adriano R Tonelli
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Kristin B Highland
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Neal F Chaisson
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Miriam Jacob
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Rahul Renapurkar
- Department of Thoracic Imaging, Imaging Institute, Cleveland Clinic, Cleveland, OH
| | - Raed A Dweik
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gustavo A Heresi
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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Abstract
Pulmonary arterial hypertension (PAH) is a common consideration when patients have unexplained signs of cardiopulmonary disease. Guidelines have been issued regarding diagnosis and management of this condition. Since multiple conditions can mimic components of PAH, the clinician should think about the patient's total clinical condition before diagnosing and categorizing it. Proper evaluation and etiologic definition are crucial to providing the appropriate therapy. This review offers a case-based guide to the evaluation of patients with suspected PAH.
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Affiliation(s)
- Akshay Bhatnagar
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Jonathan Wiesen
- Community Intensivists, Cleveland, OH, USA.,Ben Gurion University, Be'er Sheva, Israel
| | - Raed Dweik
- Interim Institute Chair, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Neal F Chaisson
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA. .,Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Senussi MH, Kantamneni PC, Omranian A, Latifi M, Hanane T, Mireles-Cabodevila E, Chaisson NF, Duggal A, Moghekar A. Revisiting Ultrasound-Guided Subclavian/Axillary Vein Cannulations: Importance of Pleural Avoidance With Rib Trajectory. J Intensive Care Med 2017; 32:396-399. [PMID: 28359216 DOI: 10.1177/0885066617701413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Centers for Disease Control and Prevention guidelines for the prevention of catheter-related bloodstream infections suggest using "a subclavian site, rather than an internal jugular or a femoral site, in adult patients." This recommendation is based on evidence of lower rates of thrombosis and catheter-related bloodstream infections in patients with subclavian central venous catheters (CVCs) compared to femoral or internal jugular sites. However, preference toward a subclavian approach to CVC insertion is hindered by increased risk of mechanical complications, especially pneumothorax, when compared to other sites. This is largely related to the proximity of the subclavian vein to the pleural space and the traditional "blind" or anatomic landmark approach used in subclavian vein cannulation. We revisit a method that may provide increased safety and avoidance of pneumothorax during ultrasound-guided subclavian/axillary vein cannulation. This is achieved by directing the needle toward the subclavian vein at a point where it traverses over the second rib, providing a protective rib shield between the vessel and pleura as a safety net for operators. The technique also allows for increased compressibility of the subclavian/axillary vein in the event of bleeding complication.
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Affiliation(s)
- Mourad H Senussi
- 1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Phani C Kantamneni
- 1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Omranian
- 1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mani Latifi
- 1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarik Hanane
- 1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Neal F Chaisson
- 1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- 1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ajit Moghekar
- 1 Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Panchabhai TS, Bandyopadhyay D, Highland KB, Chaisson NF, Aboussouan LS. A 26-Year-Old Woman With Systemic Lupus Erythematosus Presenting With Orthopnea and Restrictive Lung Impairment. Chest 2016; 149:e29-33. [DOI: 10.1016/j.chest.2015.10.053] [Citation(s) in RCA: 5] [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: 11/30/2022] Open
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Kelemen BW, Mathai SC, Tedford RJ, Damico RL, Corona-Villalobos C, Kolb TM, Chaisson NF, Harris TH, Zimmerman SL, Kamel IR, Kass DA, Hassoun PM. Right ventricular remodeling in idiopathic and scleroderma-associated pulmonary arterial hypertension: two distinct phenotypes. Pulm Circ 2015; 5:327-34. [PMID: 26064458 DOI: 10.1086/680356] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 10/13/2014] [Indexed: 11/03/2022] Open
Abstract
Patients with scleroderma (SSc)-associated pulmonary arterial hypertension (PAH) have worse survival than patients with idiopathic PAH (IPAH). We hypothesized that the right ventricle (RV) adapts differently in SSc-PAH versus IPAH. We used cardiac magnetic resonance imaging (cMRI) and hemodynamic characteristics to assess the relationship between RV morphology and RV load in patients with SSc-PAH and IPAH. In 53 patients with PAH (35 with SSc-PAH and 18 with IPAH) diagnosed by right heart catheterization (RHC), we examined cMRIs obtained within 48 hours of RHC and compared RV morphology between groups. Regression analysis was used to assess the association between diagnosis (IPAH vs. SSc-PAH) and RV measurements after adjusting for age, sex, race, body mass index (BMI), left ventricular (LV) mass, and RV load. There were no significant differences in unadjusted comparisons of cMRI measurements between the two groups. Univariable regression showed RV mass index (RVMI) was linearly associated with measures of RV load in both the overall cohort and within each group. Multivariable linear regression models revealed a significant interaction between disease type and RVMI adjusting for pulmonary vascular resistance (PVR), age, sex, race, BMI, and LV mass. This model showed a decreased slope in the relationship between RVMI and PVR in the SSc-PAH group compared with the IPAH group. RVMI varies linearly with measures of RV load. After adjusting for multiple potential confounders, patients with SSc-PAH demonstrated significantly less RV hypertrophy with increasing PVR than patients with IPAH. This difference in adaptive hypertrophy may in part explain previously observed decreased contractility and poorer survival in SSc-PAH.
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Affiliation(s)
- Benjamin W Kelemen
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA ; These authors contributed equally to this article
| | - Stephen C Mathai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA ; These authors contributed equally to this article
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rachel L Damico
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cecilia Corona-Villalobos
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Todd M Kolb
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Neal F Chaisson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Traci Housten Harris
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stefan L Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ihab R Kamel
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David A Kass
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
Pulmonary arterial hypertension (PAH) is the leading cause of death in systemic sclerosis (SSc) and affects up to 12% of all patients with SSc, with a 50% mortality rate within 3 years of PAH diagnosis. Compared with the idiopathic form of PAH (IPAH), patients with SSc-associated PAH (SSc-PAH) have a threefold increased risk of death and may receive a diagnosis late in the course of disease because of insidious onset and the high prevalence of cardiac, musculoskeletal, and pulmonary parenchymal comorbidities. Treatment with conventional forms of PAH therapy often yield poor results compared with IPAH cohorts; unfortunately, the exact reasons behind this remain poorly understood but likely include variations in the pathologic mechanisms, differences in cardiovascular response to increasing afterload, and inadequate strategies to detect and treat SSc-PAH early in its course. Current methods for screening and longitudinal evaluation of SSc-PAH, such as the 6-min walk test, transthoracic echocardiography, and MRI, each have notable advantages and disadvantages. We provide an up-to-date, focused review of SSc-PAH and how it differs from IPAH, including pathogenesis, appropriate screening for disease onset, and new approaches to treatment and longitudinal assessment of this disease.
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Affiliation(s)
- Neal F Chaisson
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD.
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Chaisson NF, Paik J, Orbai AM, Casciola-Rosen L, Fiorentino D, Danoff S, Rosen A. A novel dermato-pulmonary syndrome associated with MDA-5 antibodies: report of 2 cases and review of the literature. Medicine (Baltimore) 2012; 91:220-228. [PMID: 22732950 PMCID: PMC3726263 DOI: 10.1097/md.0b013e3182606f0b] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Melanoma differentiation-associated protein 5 (MDA-5) is a novel autoantibody frequently characterized by interstitial lung disease and a distinct cutaneous phenotype with palmar papules, ulceration, and rash. Virtually all patients have underlying dermatomyositis, but many lack the characteristic clinical myopathy associated with it. In the setting of amyopathic disease, the absence of clinically available biomarkers or clear pathologic diagnosis can complicate effective prognostic and therapeutic intervention. Until recently the presence of MDA-5 antibody associated dermato-pulmonary syndrome was described only in Asian populations. We present 2 cases of MDA-5-associated dermato-pulmonary syndrome and provide a comprehensive review of available literature.
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Affiliation(s)
- Neal F Chaisson
- From the Division of Pulmonary and Critical Care Medicine (NFC, SD) and Division of Rheumatology (JP, A-MO, LC-R, AR), Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Dermatology (DF), Stanford University School of Medicine, Palo Alto, California
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Abstract
BACKGROUND Endpoint resuscitation has been suggested as a better means to resuscitate penetrating injury. We performed computer-controlled closed-loop resuscitation using invasive cardiac output (CO) or noninvasive skeletal muscle oxygen saturation (SkMusSO(2)) via near infrared spectroscopy (NIRS). METHODS Conscious sheep received a 4.0-mm aortotomy and uncontrolled hemorrhage at t = 0 min (T0) while resuscitation started at T20 using lactated Ringer's solution. RESULTS The aortotomy rapidly decreased the mean arterial pressure (MAP) to approximately 30 mm Hg and CO to 20% to 30% of baseline. The SkMusSO(2) endpoint group required only half as much fluid through 4 hours of resuscitation as the CO endpoint group (34.9 +/- 8.4 mL/kg vs. 63.1 +/- 9.4 mL/kg). CO and MAP were lower in the SkMusSO(2) group after T60. Mean infusion volumes were 180% and 100% of the bled volume collected at autopsy in the CO and SkMusSO(2) groups. Brain and muscle oxygenation and base excess were as high or higher in the CO endpoint group. CONCLUSION Closed-loop resuscitation with either CO or SkMusSO(2) endpoints effectively performs fluid resuscitation of severe uncontrolled hemorrhagic shock. Limited resuscitation may achieve favorable clinical results with volumes less than recommended by Advanced Trauma Life Support guidelines.
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Affiliation(s)
- Neal F Chaisson
- Resuscitation Research Laboratory, Department of Anesthesiology and Physiology, University of Texas Medical Branch, Galveston 77555-0801, USA
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