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Piccolo Serafim L, Simonetto DA, Choi DH, Weister TJ, Hanson AC, Kamath PS, Gajic O, Gallo de Moraes A. DERIVATION OF A MORTALITY PREDICTION MODEL IN CRITICAL CARE PATIENTS WITH CIRRHOSIS AND SEPSIS. Shock 2024; 61:382-386. [PMID: 38517233 DOI: 10.1097/shk.0000000000002323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
ABSTRACT Objective : The aim of the study is to develop a predictive model for in-hospital mortality in critically ill patients with cirrhosis and sepsis, using clinical and laboratory data. Design : This is a retrospective cohort study. Setting: Medical and mixed intensive care units (ICUs) of a tertiary medical center. Patients : Cirrhotic adults were admitted with sepsis to the ICUs from January of 2007 to May of 2017. Interventions : None. Measurements and Main Results : Of 2,595 ICU admissions of patients with cirrhosis, 277 with first ICU admission for sepsis were included in the analysis, and 37% died in the hospital. Patients who stayed in the ICU for at least 6 h (n = 275) were considered for the multivariate model. Ten-fold cross-validation was used to estimate best parameter values and model performance, and the final model was chosen as the model maximizing area under the receiver-operating characteristic curve. Variables in order of impact were Acute Physiology and Chronic Health Evaluation (APACHE) III score, initial serum lactate, conjugated bilirubin, serum creatinine, model for end-stage liver disease score, age, body mass index, and serum hemoglobin. The final best model from cross-validation presented an area under the receiver operator characteristic curve (AUC) of 0.75, using a cut-point of 50% estimated probability, sensitivity and specificity were 0.46 and 0.90, respectively, with positive predictive value of 0.72 and negative predictive value of 0.74. These results were similar to the APACHE III only model (AUC = 0.74, sensitivity = 0.43, specificity = 0.89, positive predictive value = 0.69, negative predictive value = 0.73). Conclusion : The combination of initial serum lactate level, conjugated bilirubin, initial serum creatinine, model for end-stage liver disease score, age, body mass index, and serum hemoglobin did not yield meaningful improvement in the AUC and did not provide advantage over the APACHE III score for the prediction of in-hospital mortality in critically ill patients with cirrhosis and sepsis.
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Affiliation(s)
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Araújo B, Rivera A, Martins S, Abreu R, Cassa P, Silva M, Gallo de Moraes A. Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Crit Care 2024; 28:1. [PMID: 38167459 PMCID: PMC10759602 DOI: 10.1186/s13054-023-04727-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain. METHODS We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I2 statistics. All outcomes were submitted to random-effect models. RESULTS Our meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04-1.20; p < 0.01; I2 = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24-0.80; p < 0.01; I2 = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41-0.96; p = 0.03; I2 = 0%) compared to DL. CONCLUSION VL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients. Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685 . Registered 6 July 2023.
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Affiliation(s)
- Beatriz Araújo
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - André Rivera
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Suzany Martins
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Renatha Abreu
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Paula Cassa
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Maicon Silva
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
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Negrão Pantaleão A, Goudot G, Becari L, Jeunon V, Andrade Bello G, Gallo de Moraes A. Pulmonary embolism following an undiagnosed Paget-Schroetter syndrome: a case report and review of the literature. PHYSICIAN SPORTSMED 2023:1-7. [PMID: 37675985 DOI: 10.1080/00913847.2023.2256642] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/17/2023] [Accepted: 09/05/2023] [Indexed: 09/08/2023]
Abstract
Paget-Schroetter Syndrome (PSS) is a rare condition characterized by spontaneous thrombosis of the axillary-subclavian vein that occurs predominantly in young athletes engaged in repetitive overhead upper extremity motion, for instance, weightlifting, swimming, baseball, and tennis. PSS is usually a consequence of chronic repetitive microtrauma to the vein intima due to compression of the axillary-subclavian vein by the thoracic outlet structures. This chronic injury can then be acutely exacerbated by vigorous exercise done over a brief period, accelerating thrombus formation. Lack of PSS awareness leads to underdiagnosis, misdiagnosis, or late diagnosis, which can pose life-threatening risks to patients, including pulmonary embolism (PE) and recurrent thrombosis. This case report of a 20-year-old male college athlete exposes a PE caused by PSS, potentially worsened by a delay in diagnosis. Early suspicion and proper management are crucial for optimizing long-term outcomes and facilitating limb rehabilitation. The recommended approach involves early catheter-directed thrombolysis followed by thoracic outlet decompression.
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Affiliation(s)
- Alexandre Negrão Pantaleão
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Guillaume Goudot
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Luca Becari
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Vinicius Jeunon
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Alice Gallo de Moraes
- Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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4
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Kraus MB, Leuzinger K, Reynolds E, Gallo de Moraes A, Smith J, Sharpe EE, Quillen J, Kosiorek H, Harbell MW. Diabetes insipidus related to sedation in the intensive care unit: A review of the literature. J Crit Care 2023; 75:154233. [PMID: 36738631 DOI: 10.1016/j.jcrc.2022.154233] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/21/2022] [Accepted: 12/09/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE To identify cases of diabetes insipidus (DI) related to sedation in the ICU to determine which medications pose the greatest risk and understand patterns of presentation. MATERIALS AND METHODS We searched PubMed, Embase, Scopus, Google Scholar, and Web of Science. Search terms included "polyuria," "diabetes insipidus," "hypnotics and sedatives," "sedation," as well as individual medications. Case reports or series involving DI or polyuria related to sedation in the ICU were identified. RESULTS We identified 21 cases of diabetes insipidus or polyuria in the ICU attributed to a sedative. Dexmedetomidine was implicated in 42.9% of cases, followed by sevoflurane (33.3%) and ketamine (23.8%). Sevoflurane was implicated in all 7 cases in which it was used (100%; 95% CI 59.0%, 100.0%), dexmedetomidine in 9 of 11 cases (81.8%; 95% CI 48.2, 97.7), and ketamine in 5 of 9 cases (55.6%; 95% CI 21.2%, 86.3%). CONCLUSIONS Awareness of the potential for sedatives to cause DI may lead to greater identification with swifter medication discontinuation and subsequent resolution of DI.
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Affiliation(s)
- Molly B Kraus
- Anesthesiology, Department of Anesthesiology and Perioperative Medicine, 5777 E Mayo Blvd, Phoenix, AZ 85054, United States of America.
| | - Kahlin Leuzinger
- Anesthesiology, Department of Anesthesiology and Perioperative Medicine, 5777 E Mayo Blvd, Phoenix, AZ 85054, United States of America
| | - Emily Reynolds
- Anesthesiology, Department of Anesthesiology and Perioperative Medicine, 5777 E Mayo Blvd, Phoenix, AZ 85054, United States of America
| | - Alice Gallo de Moraes
- Medicine, Pulmonary and Critical Care Medicine, 200 First St. SW, Rochester, MN 55905, United States of America
| | - Julianna Smith
- Mayo Clinic Alix School of Medicine, 13400 E Shea Blvd, Scottsdale, AZ 85259, United States of America
| | - Emily E Sharpe
- Anesthesiology, Department of Anesthesiology and Perioperative Medicine, 200 First St. SW, Rochester, MN 55905, United States of America
| | - Jaxon Quillen
- Department of Quantitative Health Sciences, 5777 E Mayo Blvd, Phoenix, AZ 85054, United States of America
| | - Heidi Kosiorek
- Department of Quantitative Health Sciences, 5777 E Mayo Blvd, Phoenix, AZ 85054, United States of America
| | - Monica W Harbell
- Anesthesiology, Department of Anesthesiology and Perioperative Medicine, 5777 E Mayo Blvd, Phoenix, AZ 85054, United States of America
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Gary PJ, Lal A, Simonetto DA, Gajic O, Gallo de Moraes A. Acute on chronic liver failure: prognostic models and artificial intelligence applications. Hepatol Commun 2023; 7:02009842-202304010-00015. [PMID: 36972378 PMCID: PMC10043584 DOI: 10.1097/hc9.0000000000000095] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/04/2023] [Indexed: 03/29/2023] Open
Abstract
Critically ill patients presenting with acute on chronic liver failure (ACLF) represent a particularly vulnerable population due to various considerations surrounding the syndrome definition, lack of robust prospective evaluation of outcomes, and allocation of resources such as organs for transplantation. Ninety-day mortality related to ACLF is high and patients who do leave the hospital are frequently readmitted. Artificial intelligence (AI), which encompasses various classical and modern machine learning techniques, natural language processing, and other methods of predictive, prognostic, probabilistic, and simulation modeling, has emerged as an effective tool in various areas of healthcare. These methods are now being leveraged to potentially minimize physician and provider cognitive load and impact both short-term and long-term patient outcomes. However, the enthusiasm is tempered by ethical considerations and a current lack of proven benefits. In addition to prognostic applications, AI models can likely help improve the understanding of various mechanisms of morbidity and mortality in ACLF. Their overall impact on patient-centered outcomes and countless other aspects of patient care remains unclear. In this review, we discuss various AI approaches being utilized in healthcare and discuss the recent and expected future impact of AI on patients with ACLF through prognostic modeling and AI-based approaches.
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Affiliation(s)
- Phillip J Gary
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, Minnesota, USA
| | - Amos Lal
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, Minnesota, USA
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Patients with cirrhosis frequently require admission to the intensive care unit as complications arise in the course of their disease. These admissions are associated with high short- and long-term morbidity and mortality. Thus, understanding and characterizing complications and unique needs of patients with cirrhosis and acute-on-chronic liver failure helps providers identify appropriate level of care and evidence-based treatments. While there is no widely accepted critical care admission criteria for patients with cirrhosis, the presence of organ failure and primary or nosocomial infections are associated with particularly high in-hospital mortality. Optimal management of patients with cirrhosis in the critical care setting requires a system-based approach that acknowledges deviations from canonical pathophysiology. In this review, we discuss appropriate considerations and evidence-based practices for the general care of patients with cirrhosis and critical illness.
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Affiliation(s)
- Thomas N Smith
- Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota
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Choi C, Choi DH, Spears GM, Peeraphatdit TB, Serafim LP, Gajic O, Kamath PS, Shah VH, Gallo de Moraes A, Simonetto DA. Relationship Between Etiology of Cirrhosis and Survival Among Patients Hospitalized in Intensive Care Units. Mayo Clin Proc 2022; 97:274-284. [PMID: 35090753 PMCID: PMC8883528 DOI: 10.1016/j.mayocp.2021.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 05/25/2021] [Accepted: 08/06/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine short-term outcomes of patients with alcohol-associated cirrhosis (ALC) admitted to the intensive care unit (ICU) compared with other etiologies of liver disease. In addition, we investigate whether quick sequential organ failure assessment accurately predicts presence of sepsis and in-hospital mortality in critically ill patients with various etiologies of cirrhosis. METHODS A retrospective cohort of 1174 consecutive patients with cirrhosis admitted to the ICU between January of 2006 and December of 2015 was analyzed. Outcomes of interest included survival rates within the ICU, post-ICU in-hospital, or at 30 days post-ICU discharge. RESULTS Five hundred seventy-eight patients were found to have ALC with 596 in the non-ALC group. There was no significant difference in ICU mortality rates in ALC versus non-ALC cohorts (10.2% vs 11.7%, P=.40). However, patients with ALC had significantly higher post-ICU in-hospital death (10.0% vs 6.5%, P=.04) as well as higher mortality at 30-day post-ICU discharge (18.7% vs 11.2%, P<.001). Sustained alcohol abstinence did not offer survival advantage over nonabstinence. The predictive power for quick sequential organ failure assessment for sepsis and in-hospital mortality for patients with cirrhosis was limited. CONCLUSION Critically ill patients with ALC have decreased survival after ICU discharge compared with patients with other etiologies of cirrhosis, independent of alcohol abstinence.
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Affiliation(s)
- Chansong Choi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Dae Hee Choi
- Department of Internal Medicine, School of Medicine, Kangwon National University, Republic of Korea
| | - Grant M Spears
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Thoetchai Bee Peeraphatdit
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Laura Piccolo Serafim
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Alice Gallo de Moraes
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
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Servin-Rojas M, Olivas-Martinez A, Dithurbide-Hernandez M, Chavez-Vela J, Petricevich VL, García-Juárez I, Gallo de Moraes A, Zendejas B. Impact of the COVID-19 pandemic on the clinical training of last year medical students in Mexico: a cross-sectional nationwide study. BMC Med Educ 2022; 22:24. [PMID: 34998416 PMCID: PMC8742662 DOI: 10.1186/s12909-021-03085-w] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 12/13/2021] [Indexed: 06/02/2023]
Abstract
BACKGROUND The COVID-19 pandemic has brought unprecedented changes to medical education. However, no data are available regarding the impact the pandemic may have on medical training in Mexico. The aim of our study was to evaluate and identify the medical school students' perceptions of the changes in their clinical training due to the pandemic in Mexico. METHODS This was a cross-sectional study where a previous validated online survey was translated and adapted by medical education experts and applied to senior medical students from March to April of 2021. The 16-item questionnaire was distributed online combining dichotomous, multiple-choice, and 5-point Likert response scale questions. Descriptive and multivariate analyses were performed to compare the student's perceptions between public and private schools. RESULTS A total of 671 responses were included in the study period. Most participants were from public schools (81%) and female (61%). Almost every respondent (94%) indicated it was necessary to obtain COVID-19 education, yet only half (54%) received such training. Students in private schools were less likely to have their clinical instruction canceled (53% vs. 77%, p = 0.001) and more likely to have access to virtual instruction (46% vs. 22%, p = 0.001) when compared to students from public schools. Four out of every five students considered their training inferior to that of previous generations, and most students (82%) would consider repeating their final year of clinical training. CONCLUSIONS The impact of the COVID-19 on medical education in Mexico has been significant. Most final-year medical students have been affected by the cancellation of their in-person clinical instruction, for which the majority would consider repeating their final year of training. Efforts to counterbalance this lack of clinical experience with virtual or simulation instruction are needed.
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Affiliation(s)
| | | | | | - Julio Chavez-Vela
- Faculty of Medicine, Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos, Mexico
| | - Vera L Petricevich
- Faculty of Medicine, Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos, Mexico
| | - Ignacio García-Juárez
- Liver Transplant Unit, Instituto Nacional de Ciencias Médicas Y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Benjamin Zendejas
- Department of Surgery, Boston Children Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Piccolo Serafim L, Simonetto DA, Anderson AL, Choi DH, Weister TJ, Hanson AC, Kamath PS, Gajic O, Gallo de Moraes A. Clinical Effect of Systemic Steroids in Patients with Cirrhosis and Septic Shock. Shock 2021; 56:916-920. [PMID: 34132218 DOI: 10.1097/shk.0000000000001822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Evidence regarding the utility of systemic steroids in treating patients with cirrhosis and septic shock remains equivocal. This study aimed to evaluate and elucidate the association of steroid use with outcomes and adverse effects in a cohort of patients with cirrhosis and septic shock. PATIENTS AND METHODS Retrospective cohort study of patients with cirrhosis and septic shock admitted to a tertiary hospital intensive care unit (ICU) from January 2007 to May 2017, using a validated ICU Datamart. Patients who received vasopressors within 6 h of ICU admission were included in the multivariate analysis. The effect of steroids on outcomes was evaluated using multivariable regression, adjusting for confounding variables. RESULTS Out of 179 admissions of patients with cirrhosis and septic shock, 56 received steroids during the ICU admission. Patients who received steroids received a higher total dose of vasopressors (91.2 mg vs. 39.1 mg, P = 0.04) and had a lower initial lactate level (1.8 mmol/L vs. 2.6 mmol/L, P = 0.007). The multivariate analysis included 117 patients and showed no significant differences in mortality, length of ICU admission, or length of hospital stay. Bleeding events, delirium, and renal-replacement therapy requirements were also not associated with the use of steroids. CONCLUSION The use of systemic steroids was more prevalent in cirrhotic patients with higher vasopressor requirements. It was not associated with decreased mortality or increased ICU- and hospital-free days, or to adverse effects.
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Affiliation(s)
- Laura Piccolo Serafim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Alexandra L Anderson
- Division of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Dae Hee Choi
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Timothy J Weister
- Division of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Andrew C Hanson
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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10
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Gallo de Moraes A, Clain J. Family Members of Transferred Critically Ill Patients Also Need Care. Chest 2021; 160:793-794. [PMID: 34488951 DOI: 10.1016/j.chest.2021.04.052] [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] [Received: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alice Gallo de Moraes
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN.
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11
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Aragon Pinto C, Iyer VN, Albitar HAH, Anderson A, Cajigas H, Simonetto DA, Krowka MJ, DuBrock HM, Gallo de Moraes A. Outcomes of liver transplantation in patients with hepatopulmonary syndrome in the pre and post-MELD eras: A systematic review. Respir Med Res 2021; 80:100852. [PMID: 34418867 DOI: 10.1016/j.resmer.2021.100852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/15/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The lack of large hepatopulmonary syndrome cohorts undergoing liver transplantation (LT) has resulted in limited information about post-LT outcomes and expectations. METHODS The long and short-term outcomes of LT in patients with hepatopulmonary syndrome (HPS) were evaluated before and after the implementation of Model for Endstage Liver Disease (MELD) score in 2002, granting exception points for patients with HPS. PubMed/Medline, Embase, Web of Science and Scopus databases were searched for published and unpublished studies from 01/1990 to 04/2019. Studies that included HPS patients who underwent LT and reported post-LT outcomes and HPS severity were reviewed. After reviewing the full text of 1421 articles, 30 were included in the pre-MELD era (before 2002) and 60 in the post-MELD era. RESULTS A total of 598 patients (210 children and 388 adults) with HPS who underwent LT were included in this systematic review. In children, 5-year survival probability was similar in the pre and post-MELD groups (85.7% vs. 97.4; p = 0.09). Median post-transplant PaO2 in room air was higher in the post-MELD group (71 [53-87] vs. 97 [80-108] mmHg: p = 0.008). In adults, 5-year survival probability was higher in the post-MELD era (73 vs. 87.3%; p = 0.008). Median post-transplant PaO2 in room air was higher in post-MELD group (75 [63-85] vs. 87 [75-95] mmHg; p = 0.001).. CONCLUSIONS After MELD exception implementation, survival rates and post-transplant oxygenation improved in adult patients with HPS who underwent liver transplantation, whereas only post-transplant oxygenation improved in children.
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Affiliation(s)
- Catarina Aragon Pinto
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA; Mayo Epidemiology and Translational Research in Intensive Care group (METRIC), Mayo Clinic, Rochester, MN, USA
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Alexandra Anderson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hector Cajigas
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA; Mayo Epidemiology and Translational Research in Intensive Care group (METRIC), Mayo Clinic, Rochester, MN, USA.
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12
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Choi C, Lennon RJ, Choi DH, Serafim LP, Allen AM, Kamath PS, Shah VH, de Moraes AG, Simonetto DA. Relationship Between Body Mass Index and Survival Among Critically Ill Patients With Cirrhosis. J Intensive Care Med 2021; 37:817-824. [PMID: 34219539 DOI: 10.1177/08850666211029827] [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] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Obesity paradox is a phenomenon in which obesity increases the risk of obesity-related chronic diseases but paradoxically is associated with improved survival among obese patients with these diagnoses. OBJECTIVES The aim of this study was to explore the obesity paradox among critically ill patients with cirrhosis admitted to the Intensive Care Unit. METHODS A retrospective cohort of 1,143 consecutive patients with cirrhosis admitted to the ICU between January of 2006 and December of 2015 was analyzed. Primary outcome of interest was in-hospital mortality with secondary end points including ICU and short-term mortality at 30 days post ICU admission. RESULTS Logistic regression with generalized additive models was used, controlling for clinically relevant and statistically significant factors to determine the adjusted relationship between body mass index (BMI) and ICU, post-ICU in-hospital, and 30 day mortality following ICU discharge. ICU and hospital length of stay was similar across all BMI classes. Adjusted ICU mortality was also similar when stratified by BMI. However, a significant reduction in post-ICU hospital mortality was observed in class I and II obese patients with cirrhosis (BMI 30-39.9 kg/m2) compared to normal BMI (OR = 0.41; 95% CI, 0.20 to 0.83; P = 0.014). Similarly, overweight (BMI 25-29.9 kg/m2) and class I and II obese patients with cirrhosis had significantly lower 30-day mortality following ICU discharge (OR = 0.52, 95% CI 0.31 to 0.87; P = 0.014; OR = 0.50, 95% CI 0.29 to 0.86; P = 0.012, respectively) compared to those with normal BMI. CONCLUSION The signal of obesity paradox is suggested among critically ill patients with cirrhosis.
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Affiliation(s)
- Chansong Choi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan J Lennon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Dae Hee Choi
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, Gangwon, Republic of Korea
| | - Laura Piccolo Serafim
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alice Gallo de Moraes
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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13
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Azoulay É, Castro P, Maamar A, Metaxa V, de Moraes AG, Voigt L, Wallet F, Klouche K, Picard M, Moreau AS, Van De Louw A, Seguin A, Mokart D, Chawla S, Leroy J, Böll B, Issa N, Levy B, Hemelaar P, Fernandez S, Munshi L, Bauer P, Schellongowski P, Joannidis M, Moreno-Gonzalez G, Galstian G, Darmon M, Valade S. Outcomes in patients treated with chimeric antigen receptor T-cell therapy who were admitted to intensive care (CARTTAS): an international, multicentre, observational cohort study. Lancet Haematol 2021; 8:e355-e364. [PMID: 33894170 DOI: 10.1016/s2352-3026(21)00060-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T-cell therapy can induce side-effects such as cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS), which often require intensive care unit admission. The aim of this study was to describe management of critically ill CAR T-cell recipients in intensive care. METHODS This international, multicentre, observational cohort study was done in 21 intensive care units in France, Spain, the USA, the UK, Russia, Canada, Germany, and Austria. Eligible patients were aged 18 years or older; had received CAR T-cell therapy in the past 30 days; and had been admitted to intensive care for any reason. Investigators retrospectively included patients admitted between Feb 1, 2018, and Feb 1, 2019, and prospectively included patients admitted between March 1, 2019, and Feb 1, 2020. Demographic, clinical, laboratory, treatment, and outcome data were extracted from medical records. The primary endpoint was 90-day mortality. Factors associated with mortality were identified using a Cox proportional hazard model. FINDINGS 942 patients received CAR T-cell therapy, of whom 258 (27%) required admission to intensive care and 241 (26%) were included in the analysis. Admission to intensive care was needed within median 4·5 days (IQR 2·0-7·0) of CAR T-cell infusion. 90-day mortality was 22·4% (95% CI 17·1-27·7; 54 deaths). At initial evaluation on admission, isolated cytokine release syndrome was identified in 101 patients (42%), cytokine release syndrome and ICANS in 93 (39%), and isolated ICANS in seven (3%) patients. Grade 3-4 cytokine release syndrome within 1 day of admission to intensive care was found in 50 (25%) of 200 patients and grade 3-4 ICANS in 38 (35%) of 108 patients. Bacterial infection developed in 30 (12%) patients. Life-saving treatments were used in 75 (31%) patients within 24 h of admission to intensive care, primarily vasoactive drugs in 65 (27%) patients. Factors independently associated with 90-day mortality by multivariable analysis were frailty (hazard ratio 2·51 [95% CI 1·37-4·57]), bacterial infection (2·12 [1·11-4·08]), and lifesaving therapy within 24 h of admission (1·80 [1·05-3·10]). INTERPRETATION Critical care management is an integral part of CAR T-cell therapy and should be standardised. Studies to improve infection prevention and treatment in these high-risk patients are warranted. FUNDING Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique.
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Affiliation(s)
- Élie Azoulay
- Critical Care Department, APHP, Hôpital Saint-Louis, University of Paris, Paris, France.
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Adel Maamar
- Critical Care and Infectious Diseases Department, Rennes University Hospital, Rennes, France; INSERM CIC-1414, Faculté de Médecine, Université Rennes 1, Rennes, France
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Louis Voigt
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Centre, New York City, NY, USA; Department of Anesthesiology, Weill Cornell Medical College, New York City, NY, USA
| | - Florent Wallet
- Critical Care Department, HCL, Hôpital Lyon Sud, University of Lyon, Lyon, France
| | - Kada Klouche
- Critical Care Department, Hôpital Lapeyronie, University of Montpellier, Montpellier, France
| | - Muriel Picard
- Critical Care Department, Institut Universitaire du Cancer de Toulouse-Oncopole, University Teaching Hospital of Toulouse, Toulouse, France
| | - Anne-Sophie Moreau
- Critical Care Department, Lille University Salengro Hospital, Lille, France
| | - Andry Van De Louw
- Division of Pulmonary and Critical Care Medicine, Penn State Health Milton S Hershey Medical Centre, Hershey, PA, USA
| | - Amélie Seguin
- Critical Care Department, Nantes University Hospital, Nantes, France
| | - Djamel Mokart
- Critical Care Department, Institut Paoli-Calmettes, Marseille, France
| | - Sanjay Chawla
- Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Centre, New York City, NY, USA; Department of Anesthesiology, Weill Cornell Medical College, New York City, NY, USA
| | - Julien Leroy
- Critical Care Department, APHP, Hôpital Saint-Louis, University of Paris, Paris, France
| | - Boris Böll
- Department I of Internal Medicine, Haematology and Oncology, Intensive Care Medicine, Centre for Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, Cologne, Germany
| | - Nahema Issa
- Critical Care Department, Hôpital Saint-André, University of Bordeaux, Bordeaux, France
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy, France
| | - Pleun Hemelaar
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Sara Fernandez
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter Schellongowski
- Intensive Care Unit 13i2, Department of Medicine I, Medical University of Vienna, Centre of Excellence of Medical Intensive Care (CEMIC), Vienna, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Gabriel Moreno-Gonzalez
- Intensive Care Unit, Bellvitge University Hospital, Catalan Institute of Oncology L'Hospitalet, Bellvitge Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Gennadii Galstian
- Department of Intensive Care of the National Research Centre for Haematology, Moscow Russia
| | - Michael Darmon
- Critical Care Department, APHP, Hôpital Saint-Louis, University of Paris, Paris, France
| | - Sandrine Valade
- Critical Care Department, APHP, Hôpital Saint-Louis, University of Paris, Paris, France
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14
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Kaul V, Gallo de Moraes A, Khateeb D, Greenstein Y, Winter G, Chae J, Stewart NH, Qadir N, Dangayach NS. Medical Education During the COVID-19 Pandemic. Chest 2021; 159:1949-1960. [PMID: 33385380 PMCID: PMC7772576 DOI: 10.1016/j.chest.2020.12.026] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 12/27/2022] Open
Abstract
All aspects of medical education were affected by the COVID-19 pandemic. Several challenges were experienced by trainees and programs alike, including economic repercussions of the pandemic; social distancing affecting the delivery of medical education, testing, and interviewing; the surge of patients affecting redeployment of personnel and potential compromises in core training; and the overall impact on the wellness and mental health of trainees and educators. The ability of medical teams and researchers to peer review, conduct clinical research, and keep up with literature was similarly challenged by the rapid growth in peer-reviewed and preprint literature. This article reviews these challenges and shares strategies that institutions, educators, and learners adopted, adapted, and developed to provide quality education during these unprecedented times.
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Affiliation(s)
- Viren Kaul
- Crouse Health/Upstate Medical University.
| | | | | | | | | | - JuneMee Chae
- Mayo Clinic Health System-Franciscan Healthcare at La Crosse
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15
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Affiliation(s)
- Eduardo R Argaiz
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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16
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Sher T, Burger CD, DeMartino ES, de Moraes AG, Sharp RR. Resuscitation and COVID-19: Recalibrating Patient and Family Expectations During a Pandemic. Mayo Clin Proc 2020; 95:1848-1851. [PMID: 32861329 PMCID: PMC7323655 DOI: 10.1016/j.mayocp.2020.06.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
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17
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Gallo de Moraes A, Carroll CL, Schmidt GA, Pendleton KM. All That Glitters Isn't Gold: Critical Care in the Time of Coronavirus Disease 2019. Chest 2020; 158:877-878. [PMID: 32470388 PMCID: PMC7248627 DOI: 10.1016/j.chest.2020.04.071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Christopher L Carroll
- Division of Pediatric Critical Care, Connecticut Children's Medical Center, Hartford, CT
| | - Gregory A Schmidt
- Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, IA
| | - Kathryn M Pendleton
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN
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18
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Gutierrez C, Brown ART, Herr MM, Kadri SS, Hill B, Rajendram P, Duggal A, Turtle CJ, Patel K, Lin Y, May HP, Gallo de Moraes A, Maus MV, Frigault MJ, Brudno JN, Athale J, Shah NN, Kochenderfer JN, Dharshan A, Beitinjaneh A, Arias AS, McEvoy C, Mead E, Stephens RS, Nates JL, Neelapu SS, Pastores SM. The chimeric antigen receptor-intensive care unit (CAR-ICU) initiative: Surveying intensive care unit practices in the management of CAR T-cell associated toxicities. J Crit Care 2020; 58:58-64. [PMID: 32361219 DOI: 10.1016/j.jcrc.2020.04.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [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: 02/27/2020] [Revised: 03/25/2020] [Accepted: 04/13/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE A task force of experts from 11 United States (US) centers, sought to describe practices for managing chimeric antigen receptor (CAR) T-cell toxicity in the intensive care unit (ICU). MATERIALS AND METHODS Between June-July 2019, a survey was electronically distributed to 11 centers. The survey addressed: CAR products, toxicities, targeted treatments, management practices and interventions in the ICU. RESULTS Most centers (82%) had experience with commercial and non-FDA approved CAR products. Criteria for ICU admission varied between centers for patients with Cytokine Release Syndrome (CRS) but were similar for Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS). Practices for vasopressor support, neurotoxicity and electroencephalogram monitoring, use of prophylactic anti-epileptic drugs and tocilizumab were comparable. In contrast, fluid resuscitation, respiratory support, methods of surveillance and management of cerebral edema, use of corticosteroid and other anti-cytokine therapies varied between centers. CONCLUSIONS This survey identified areas of investigation that could improve outcomes in CAR T-cell recipients such as fluid and vasopressor selection in CRS, management of respiratory failure, and less common complications such as hemophagocytic lymphohistiocytosis, infections and stroke. The variability in specific treatments for CAR T-cell toxicities, needs to be considered when designing future outcome studies of critically ill CAR T-cell patients.
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Affiliation(s)
- Cristina Gutierrez
- Department of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States of America.
| | - Anne Rain T Brown
- Clinical Pharmacy Specialist in Critical Care, Department of Pharmacy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States of America
| | - Megan M Herr
- Transplant and Cellular Therapy Program, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States of America
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States of America
| | - Brian Hill
- Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, United States of America
| | - Prabalini Rajendram
- Department of Critical Care, Cleveland Clinic, Cleveland Clinic Lerner School of Medicine, Cleveland, OH, United States of America
| | - Abhijit Duggal
- Medical Intensive Care Unit, Cleveland Clinic and Assistant Professor of Medicine, Lerner School of Medicine, Cleveland Clinic, Cleveland, OH, United States of America
| | - Cameron J Turtle
- Anderson Family Endowed Chair for Immunotherapy, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, United States of America
| | - Kevin Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle Cancer Alliance, Seattle, WA, United States of America
| | - Yi Lin
- Division of Hematology, Division of Experimental Pathology, Mayo Clinic, Rochester, MN, United States of America
| | - Heather P May
- Mayo Clinic College of Medicine and Science, Critical Care Clinical Pharmacist, Department of Pharmacy, Mayo Clinic, Rochester, MN, United States of America
| | - Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, United States of America
| | - Marcela V Maus
- Cellular Immunotherapy Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Mathew J Frigault
- Cellular Immunotherapy Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Jennifer N Brudno
- Assistant Research Physician, Surgery Branch, National Cancer Institute, National Institutes of Health, United States of America
| | - Janhavi Athale
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States of America
| | - Nirali N Shah
- Pediatric Oncology Branch, National Cancer Institute, National Institute of Health, United States of America
| | - James N Kochenderfer
- Surgery Branch of the National Cancer Institute, National Cancer Institute, National Institute of Health, United States of America
| | - Ananda Dharshan
- Intensive Care Unit, Roswell Park Comprehensive Cancer Center, Department of Anesthesiology, Jacobs School of Medicine & Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, United States of America
| | - Amer Beitinjaneh
- Department of Medicine, Division of Transplantation and Cellular Therapy, University of Miami, Miami, FL, United States of America
| | - Alejandro S Arias
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Miami, Miami, FL, United States of America
| | - Colleen McEvoy
- Stem Cell Transplant and Oncology Intensive Care Unit, Assistant Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
| | - Elena Mead
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, United States of America
| | - R Scott Stephens
- Oncology and Bone Marrow Transplant Critical Care, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Joseph L Nates
- Surgical and Medical Intensive Care Units, Division of Anesthesiology and Critical Care, Department of Critical Care, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States of America
| | - Sattva S Neelapu
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Stephen M Pastores
- Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, United States of America
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19
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Gallo de Moraes A, Holets SR, Tescher AN, Elmer J, Arteaga GM, Schears G, Patch RK, Bohman JK, Oeckler RA. The Clinical Effect of an Early, Protocolized Approach to Mechanical Ventilation for Severe and Refractory Hypoxemia. Respir Care 2020; 65:413-419. [PMID: 31992664 DOI: 10.4187/respcare.07243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND ARDS remains a source of significant morbidity and mortality in the critically ill patient. The mainstay of therapy entails invasive mechanical ventilation utilizing a lung-protective strategy designed to limit lung injury associated with excessive stress and strain while the underlying etiology of respiratory failure is identified and treated. Less is understood about what to do once conventional ventilation parameters have been optimized but the patient's respiratory status remains unchanged or worsens. In 2015, a protocolized, stepwise approach to mechanical ventilation with partially automated and clearly defined thresholds for management changes was implemented at our institution. We hypothesized that, by identifying appropriate patients earlier, time-to-escalation and rescue therapy implementation would be shortened. METHODS Subjects with severe ARDS, treated with prone positioning based on our institution's protocolized approach from December 2013 to August 2016 were included. Their baseline characteristics, severity of illness scores, and mechanical ventilation parameters were collected and analyzed. RESULTS Baseline characteristics, tidal volumes, PaO2 /FIO2 , duration of ventilation after proning, and mortality were similar in both groups. Median (interquartile range [IQR]) PEEP at the time of proning was higher after the protocol implementation (12.5 cm H2O [IQR 6.5-19.4] vs 18 cm H2O [IQR 10-22], P = .386), and mean (IQR) respiratory system driving pressure was lower (16 cm H2O [IQR 13-36.2] vs 12 cm H2O [IQR 9-19.6], P = .029). Median (IQR) time from refractory hypoxemia identification to proning was shorter after protocol implementation (42.2 h [IQR 6.83-347.2] vs 16.3 h [IQR 1-99.7], I = .02), and PaO2 /FIO2 at 1 h after proning was higher. ICU and hospital LOS were shorter after the protocol implementation. CONCLUSIONS Following the implementation of an early, evidence-based, protocolized approach to optimizing mechanical ventilation, subjects with true refractory hypoxemia were identified earlier and time to proning was significantly shorter. Despite improvement in the evaluation and management of refractory hypoxemia as well as time to initiation of prone positioning, mortality was unchanged and there was variation in the duration of the position.
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Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Steven R Holets
- Department of Respiratory Care, Mayo Clinic, Rochester, Minnesota
| | - Ann N Tescher
- Department of Nursing, Mayo Clinic, Rochester, Minnesota
| | - Jennifer Elmer
- Department of Nursing, Mayo Clinic, Rochester, Minnesota
| | - Grace M Arteaga
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Gregory Schears
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Richard K Patch
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota.,Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota
| | - John K Bohman
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, Minnesota
| | - Richard A Oeckler
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota.
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20
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Fonseca Fuentes X, Kashyap R, Hays JT, Chalmers S, Lama von Buchwald C, Gajic O, Gallo de Moraes A. VpALI-Vaping-related Acute Lung Injury: A New Killer Around the Block. Mayo Clin Proc 2019; 94:2534-2545. [PMID: 31767123 DOI: 10.1016/j.mayocp.2019.10.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/14/2019] [Indexed: 01/21/2023]
Abstract
The use of electronic cigarettes, known as vaping, has become increasingly popular over the past decade, particularly in the adolescent and young adult population, often exposing users to harmful chemicals. Vaping has been associated with a heterogeneous group of pulmonary disease. Recently, a multistate epidemic has emerged surrounding vaping-related acute lung injury, prompting the Centers for Disease Control and Prevention to list an official health advisory. In this review, we describe the current literature on the epidemiology, clinical significance, as well as recommended evaluation and treatment of vaping-related lung injury.
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Affiliation(s)
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - J Taylor Hays
- Department of General Internal Medicine, Nicotine Dependence Center, Mayo Clinic, Rochester, MN
| | - Sarah Chalmers
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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21
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de Moraes AG, O’Horo JC. In inpatients with community-acquired pneumonia, a bundled intervention with steroids did not reduce length of stay. Ann Intern Med 2019; 171:JC52. [PMID: 31739335 DOI: 10.7326/acpj201911190-052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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22
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Simonetto DA, Piccolo Serafim L, Gallo de Moraes A, Gajic O, Kamath PS. Management of Sepsis in Patients With Cirrhosis: Current Evidence and Practical Approach. Hepatology 2019; 70:418-428. [PMID: 30516866 DOI: 10.1002/hep.30412] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/30/2018] [Indexed: 12/13/2022]
Abstract
Sepsis in patients with cirrhosis is associated with high mortality. An impaired immune response accounts for the increased infection risk observed in these patients. Hemodynamic and systemic changes suggestive of sepsis may be observed in patients with cirrhosis in the absence of infection; therefore, diagnosis and treatment of sepsis may be delayed. The optimal management of the critically ill patient with sepsis and cirrhosis has not been well established and is generally extrapolated from consensus guidelines and expert recommendations made for management of patients without cirrhosis with sepsis. Despite the lack of strong evidence, we propose a contemporary pragmatic approach to sepsis management in patients with cirrhosis, including the choice of fluids, vasopressors, and antibiotics.
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Affiliation(s)
- Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Laura Piccolo Serafim
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
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23
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Abstract
Diabetes affects approximately 30 million persons in the United States. Diabetes ketoacidosis is one of the most serious and acute complications of diabetes. At the time of presentation and during treatment of diabetic ketoacidosis (DKA), several metabolic and electrolyte derangements can ultimately result in respiratory compromise. Most commonly, hypokalemia, hypomagnesemia and hypophosphatemia can eventually lead to respiratory muscles failure. Furthermore, tachypnea, hyperpnea and more severely, Kussmaul breathing pattern can develop. Also, hydrostatic and non-hydrostatic pulmonary edema can occur secondary to volume shifts into the extracellular space and secondary to increased permeability of the pulmonary capillaries. The presence of respiratory failure in patients with DKA is associated with higher morbidity and mortality. Being familiar with the causes of respiratory compromise in DKA, and how to treat them, may represent better outcomes for patients with DKA.
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Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Salim Surani
- Division of Pulmonary, Critical Care and Sleep Medicine, Texas A and M University, Corpus Christy, TX 78412, United States
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Durani U, Gallo de Moraes A, Beachey J, Nelson D, Robinson S, Anavekar NS. Epithelioid angiosarcoma: A rare cause of pericarditis and pleural effusion. Respir Med Case Rep 2018; 24:77-80. [PMID: 29977765 PMCID: PMC6010620 DOI: 10.1016/j.rmcr.2018.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 11/25/2022] Open
Abstract
Angiosarcomas are rare cancers accounting for less than 2% of all soft tissue sarcomas. We report the case of an unusual presentation of pleural epithelioid angiosarcoma in a patient with constrictive pericarditis and recurrent pleural effusion. A 62 year old smoker presented with acute chest pain. ECG showed diffuse elevation of ST segments in the precordial leads. After extensive evaluation, he was diagnosed with viral pericarditis and treated with colchicine. Two weeks later the patient presented to the emergency department with a large right pleural effusion. Evaluation of the pleural fluid obtained from a thoracentesis revealed an exudative effusion with negative microbial studies and no evidence of malignant cells. His pleural effusion re-accumulated rapidly, requiring repeated thoracenteses over several weeks. Medical thoracoscopy was performed and pleural biopsy revealed primary pleural epithelioid angiosarcoma. Staging PET scan revealed malignant enhancement of right pleura, pericardium, right iliac bone and right shoulder. He died suddenly within 6 weeks of diagnosis, prior to initiating palliative chemotherapy. Pleural angiosarcoma should be considered in the differential diagnosis of recurrent pleural effusions of unknown etiology. Negative cytology does not rule out the diagnosis; excisional biopsy is required. Reported risk factors include asbestos exposure, prior chest radiation, active smoking and history of complicated pleural tuberculosis. Pleural epithelioid angiosarcomas carry a very poor prognosis, with the majority of patients dying within months of diagnosis.
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Affiliation(s)
- Urshila Durani
- Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Joel Beachey
- Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Darlene Nelson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Steven Robinson
- Department of Medicine, Division of Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.,Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Abstract
We highlight a rare presentation of Legionella infection in a 77-year-old woman with a clinical diagnosis of giant cell arteritis 2 months prior to presentation. She was started on 60 mg prednisone that was tapered to 10 mg after 4 weeks following her diagnosis. She presented with a 1-month progressive dyspnoea in the absence of any other symptoms. Her exposure history was significant only for a recent trip to Florida where she stayed at a hotel. Initial laboratory workup was significant for hyponatraemia (127 mmol/L). Workup including bronchoalveolar lavage (BAL) and induced sputum for gram stain, acid fast stain and bacterial culture were negative for Pneumocystis jirovecii pneumonia and other opportunistic infectious agents. However, BAL was positive for Legionella pneumophila via PCR that was confirmed by a positive urinary Legionella antigen. The patient received treatment with levofloxacin that led to full resolution of her symptoms.
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Affiliation(s)
- Hasan Ahmad Hasan Albitar
- Faculty of Medicine, University of Jordan, Amman, Jordan.,Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota, USA
| | - Kaiser G Lim
- Department of Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota, USA
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26
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Gallo de Moraes A, Vakil A, Moua T. Patent foramen ovale in idiopathic pulmonary arterial hypertension: Long-term risk and morbidity. Respir Med 2016; 118:53-57. [PMID: 27578471 DOI: 10.1016/j.rmed.2016.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/29/2016] [Accepted: 07/12/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Little is known about the presence of patent foramen ovale in idiopathic pulmonary arterial hypertension. While there is suspected worsening of hypoxemia confounding assessment and management of pulmonary hypertension, as well as possible increased morbidity from paradoxical emboli, there may be theoretical relief of worsening right-sided pressures by the same mechanism of right-to-left shunting. METHODS Retrospective review of consecutive patients diagnosed with idiopathic pulmonary arterial hypertension (WHO Group 1) via right heart catheterization, from 1998 to 2010. All patients also underwent a four chamber transthoracic echocardiogram with agitated saline contrast for the evaluation of patent foramen ovale. Primary clinical data was collected and compared between patients with and without patent foramen ovale along with univariable and multivariable predictors of long term survival. RESULTS One hundred and fifty five patients were included in the study, 42 with patent foramen ovale (27%). Patients with patent foramen ovale were younger at pulmonary arterial hypertension diagnosis and trended towards higher right ventricular systolic pressures on echocardiography and mean pulmonary arterial pressures by right heart catheterization. Predictors of mortality included age, diffusing capacity for carbon monoxide, and severe hypoxemia. Only diffusing capacity and age were predictive of mortality after adjustment for a priori covariables. CONCLUSION Patent foramen ovale is seen in a quarter of patients with idiopathic pulmonary arterial hypertension and associated with increased prevalence of severe hypoxemia but had no effect on long term survival.
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Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Abhay Vakil
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Teng Moua
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
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Lenchus JD, Biehl M, Cabrera J, Moraes AGD, Dezfulian C. In-Hospital Management and Follow-Up Treatment of Venous Thromboembolism: Focus on New and Emerging Treatments. J Intensive Care Med 2016; 32:299-311. [PMID: 27179058 DOI: 10.1177/0885066616648265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep venous thrombosis (DVT), is a major cause of morbidity and mortality of particular relevance for intensivists and hospitalists. Acute VTE is usually managed with parenteral unfractionated heparin or low-molecular-weight heparin, followed by an oral vitamin K antagonist. Data are lacking for optimal treatment of less common occurrences, such as upper extremity DVT, and for approaches such as thrombolysis for PE associated with early signs of hemodynamic compromise or inferior vena cava filters when anticoagulation is contraindicated. Direct oral anticoagulants (DOACs) including apixaban, dabigatran, edoxaban, and rivaroxaban are now added to the armamentarium of agents available for acute management of VTE and/or reducing the risk of recurrence. This review outlines an algorithmic approach to acute VTE treatment: from aggressive therapies when anticoagulation may be inadequate, to alternative choices when anticoagulation is contraindicated, to anticoagulant options in the majority of patients in whom anticoagulation is appropriate. Evidence-based guidelines and the most recent DOAC clinical trial data are discussed in the context of the standard of care. Situations and treatment approaches for which data are unavailable or insufficient are identified. VTE therapy in care transitions is discussed, as are choices for secondary prevention.
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Affiliation(s)
- Joshua D Lenchus
- 1 Department of Clinical Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,2 Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michelle Biehl
- 3 Department of Pulmonary and Critical Care Medicine, Sanford Health, University of South Dakota Medical Center, Sioux Falls, SD, USA
| | - Jorge Cabrera
- 4 Department of Biomedical Science, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Alice Gallo de Moraes
- 5 Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Cameron Dezfulian
- 6 Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Racedo Africano CJ, Gallo de Moraes A, Smischney NJ. Perspectives on a Multidisciplinary Team Approach to Implementation of Planned Emergent Use Research. Med Sci Monit 2015; 21:2794-800. [PMID: 26386913 PMCID: PMC4581686 DOI: 10.12659/msm.894327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/14/2022] Open
Abstract
In this paper we present the viewpoints of three members of a research team, on the approach to teamwork in the development of an emergent use clinical trial when dealing with diversity of opinions, in order to facilitate stakeholder buy-in. We also discuss a specific approach to the coordination of the team members, which in our opinion had a positive impact on the implementation of the project. We also comment on the influence of the team organization in the timeline and completion of a clinical trial. We hope to start a conversation on team dynamics in the design of clinical trials, especially in the context of emergent use research.
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Affiliation(s)
| | - Alice Gallo de Moraes
- Department of Medicine - Pulmonary and Critical Care Division, Mayo Clinic, Rochester, MN, USA
| | - Nathan J Smischney
- Department of Anesthesiology - Critical Care Division and Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
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Gallo de Moraes A, Patel PA, Mahal E, Kramer CL, Diaz Soto JC, Moua T. Acute fever and seizure in a patient with recent atrial fibrillation ablation. Heart Lung 2015; 44:314-6. [PMID: 26021546 DOI: 10.1016/j.hrtlng.2015.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 05/01/2015] [Accepted: 05/03/2015] [Indexed: 12/01/2022]
Abstract
Patients undergoing radiofrequency ablation for treatment of atrial fibrillation may present critically ill with complications of atrial esophageal fistula, commonly manifesting as neurologic deficits and septicemia difficult to distinguish from other acute etiologies without a high index of suspicion. The temporal variability in fistula formation and symptom presentation, along with their nonspecific features, makes diagnosis often a late finding with historically high morbidity and mortality. We present a patient admitted to a medical intensive care unit with status epilepticus and recurrent positive blood cultures for organisms commonly associated with the gastrointestinal (GI) tract. Chest computed tomography (CT) without contrast, transthoracic echocardiography, and initial neurologic imaging were unhelpful. A diagnosis was ultimately made by upper endoscopy of the esophagus after hematemesis with suspicion for GI bleed, at which point surgical intervention was attempted but without success. This case reviews the clinical features of atrial esophageal fistula formation and its initial diagnosis and management.
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Affiliation(s)
- Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Pratik A Patel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Mahal
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Christopher L Kramer
- Department of Neurology, Division of Critical Care, Mayo Clinic, Rochester, MN, USA
| | | | - Teng Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
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Smischney NJ, Hoskote SS, Gallo de Moraes A, Racedo Africano CJ, Carrera PM, Tedja R, Pannu JK, Hassebroek EC, Reddy DRS, Hinds RF, Thakur L. Ketamine/propofol admixture (ketofol) at induction in the critically ill against etomidate (KEEP PACE trial): study protocol for a randomized controlled trial. Trials 2015; 16:177. [PMID: 25909406 PMCID: PMC4409710 DOI: 10.1186/s13063-015-0687-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/26/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Endotracheal intubation (ETI) is commonly performed as a life-saving procedure in the intensive care unit (ICU). It is often associated with significant hemodynamic perturbations and can severely impact the outcome of ICU patients. Etomidate is often chosen by many critical care providers for the patients who are hypotensive because of its superior hemodynamic profile compared to other induction medications. However, recent evidence has raised concerns about the increased incidence of adrenal insufficiency and mortality associated with etomidate use. A combination of ketamine and propofol (known as ketofol) has been studied in various settings as an alternative induction agent. In recent years, studies have shown that this combination may provide adequate sedation while maintaining hemodynamic stability, based on the balancing of the hemodynamic effects of these two individual agents. We hypothesized that ketofol may offer a valuable alternative to etomidate in critically ill patients with or without hemodynamic instability. METHODS/DESIGN A randomized controlled parallel-group clinical trial of adult critically ill patients admitted to either a medical or surgical ICU at Mayo Clinic in Rochester, MN will be conducted. As part of planned emergency research, informed consent will be waived after appropriate community consultation and notification. Patients undergoing urgent or emergent ETI will receive either etomidate or a 1:1 admixture of ketamine and propofol (ketofol). The primary outcome will be hemodynamic instability during the first 15 minutes following drug administration. Secondary outcomes will include ICU length of stay, mortality, adrenal function, ventilator-free days and vasoactive medication use, among others. The planned sample size is 160 total patients. DISCUSSION The overall goal of this trial is to assess the hemodynamic consequences of a ketamine-propofol combination used in critically ill patients undergoing urgent or emergent ETI compared to etomidate, a medication with an established hemodynamic profile. The trial will address a crucial gap in the literature regarding the optimal induction agent for ETI in patients that may have potential or established hemodynamic instability. Greater experience with planned emergency research will, hopefully, pave the way for future prospective randomized clinical trials in the critically ill population. TRIAL REGISTRATION Clinicaltrials.gov: NCT02105415. 31 March 2014.
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Affiliation(s)
- Nathan J Smischney
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Respiratory Care, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Sumedh S Hoskote
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Carlos J Racedo Africano
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Perliveh M Carrera
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Rudy Tedja
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Jasleen K Pannu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Elizabeth C Hassebroek
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Dereddi Raja S Reddy
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Richard F Hinds
- Department of Anesthesiology, Division of Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Lokendra Thakur
- Department of Critical Care Medicine, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17822, USA.
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Gallo de Moraes A, Racedo Africano CJ, Hoskote SS, Reddy DRS, Tedja R, Thakur L, Pannu JK, Hassebroek EC, Smischney NJ. Ketamine and propofol combination ("ketofol") for endotracheal intubations in critically ill patients: a case series. Am J Case Rep 2015; 16:81-6. [PMID: 25676819 PMCID: PMC4332295 DOI: 10.12659/ajcr.892424] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation. CASE REPORT We describe 6 cases in which the combination of ketamine and propofol ("ketofol") was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥ 65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations. CONCLUSIONS This case series describes the use of the "ketofol" combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.
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Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carlos J Racedo Africano
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sumedh S Hoskote
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dereddi Raja S Reddy
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rudy Tedja
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lokendra Thakur
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jasleen K Pannu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth C Hassebroek
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nathan J Smischney
- Department of Anesthesiology, Division of Critical Care Medicine and Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
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Iacovella G, Gallo de Moraes A, Sevilla Berrios R, O'Horo J, Elmer J, Caples S, Jensen J. Outpatient Utilization of the Rapid Response Team. Chest 2014. [DOI: 10.1378/chest.1993270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Gallo de Moraes A, Iacovella G, Sevilla Berrios R, O'Horo J, Elmer J, Caples S, Jensen J. Improving Primary Team Engagement During Rapid Response Team Activations. Chest 2014. [DOI: 10.1378/chest.1993656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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34
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Sevilla Berrios R, O'Horo J, Gallo de Moraes A, Iacovella G, Elmer J, Jensen J, Caples S. Intervention Intensity in Inpatients With New vs Ongoing Decompensation. Chest 2014. [DOI: 10.1378/chest.1992812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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