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Davis JA, Manoach S, Heerdt P, Berlin DA. Management of Respiratory Failure in Hemorrhagic Shock. Ann Am Thorac Soc 2024. [PMID: 38669620 DOI: 10.1513/annalsats.202310-905cme] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 04/25/2024] [Indexed: 04/28/2024] Open
Abstract
Hemorrhagic shock results in acute respiratory failure due to respiratory muscle fatigue and inadequate pulmonary blood flow. Because positive pressure ventilation can reduce venous return and cardiac output, clinicians should use the minimum possible mean airway pressure during assisted or mechanical ventilation, particularly during episodes of severe hypovolemia. Hypoperfusion also worsens dead space fraction. Therefore, clinicians should monitor capnography during mechanical ventilation and recognize that hypercapnia may be treated with fluid resuscitation rather than increasing minute ventilation.
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Affiliation(s)
- Joshua A Davis
- NewYork-Presbyterian Weill Cornell Medical Center, 159947, Pulmonary & Critical Care Medicine , New York, New York, United States;
| | - Seth Manoach
- NewYork-Presbyterian Weill Cornell Medical Center, 159947, Pulmonary & Critical Care Medicine, New York, New York, United States
| | - Paul Heerdt
- Yale University School of Medicine, 12228, Anesthesiology, New Haven, Connecticut, United States
| | - David A Berlin
- NewYork-Presbyterian Weill Cornell Medical Center, 159947, Pulmonary and Critical Care Medicine, New York, New York, United States
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Waldrop G, Safavynia SA, Barra ME, Agarwal S, Berlin DA, Boehme AK, Brodie D, Choi JM, Doyle K, Fins JJ, Ganglberger W, Hoffman K, Mittel AM, Roh D, Mukerji SS, Der Nigoghossian C, Park S, Schenck EJ, Salazar‐Schicchi J, Shen Q, Sholle E, Velazquez AG, Walline MC, Westover MB, Brown EN, Victor J, Edlow BL, Schiff ND, Claassen J. Prolonged Unconsciousness is Common in COVID-19 and Associated with Hypoxemia. Ann Neurol 2022; 91:740-755. [PMID: 35254675 PMCID: PMC9082460 DOI: 10.1002/ana.26342] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/20/2022] [Accepted: 02/28/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this study was to estimate the time to recovery of command-following and associations between hypoxemia with time to recovery of command-following. METHODS In this multicenter, retrospective, cohort study during the initial surge of the United States' pandemic (March-July 2020) we estimate the time from intubation to recovery of command-following, using Kaplan Meier cumulative-incidence curves and Cox proportional hazard models. Patients were included if they were admitted to 1 of 3 hospitals because of severe coronavirus disease 2019 (COVID-19), required endotracheal intubation for at least 7 days, and experienced impairment of consciousness (Glasgow Coma Scale motor score <6). RESULTS Five hundred seventy-one patients of the 795 patients recovered command-following. The median time to recovery of command-following was 30 days (95% confidence interval [CI] = 27-32 days). Median time to recovery of command-following increased by 16 days for patients with at least one episode of an arterial partial pressure of oxygen (PaO2 ) value ≤55 mmHg (p < 0.001), and 25% recovered ≥10 days after cessation of mechanical ventilation. The time to recovery of command-following was associated with hypoxemia (PaO2 ≤55 mmHg hazard ratio [HR] = 0.56, 95% CI = 0.46-0.68; PaO2 ≤70 HR = 0.88, 95% CI = 0.85-0.91), and each additional day of hypoxemia decreased the likelihood of recovery, accounting for confounders including sedation. These findings were confirmed among patients without any imagining evidence of structural brain injury (n = 199), and in a non-overlapping second surge cohort (N = 427, October 2020 to April 2021). INTERPRETATION Survivors of severe COVID-19 commonly recover consciousness weeks after cessation of mechanical ventilation. Long recovery periods are associated with more severe hypoxemia. This relationship is not explained by sedation or brain injury identified on clinical imaging and should inform decisions about life-sustaining therapies. ANN NEUROL 2022;91:740-755.
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Affiliation(s)
- Greer Waldrop
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Seyed A. Safavynia
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - Megan E. Barra
- Department of PharmacyMassachusetts General HospitalBostonMAUSA
- Center for Neurotechnology and NeurorecoveryMassachusetts General HospitalBostonMAUSA
| | - Sachin Agarwal
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - David A. Berlin
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - Amelia K Boehme
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Daniel Brodie
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Jacky M. Choi
- Division of Biostatistics, Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNYUSA
| | - Kevin Doyle
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Joseph J. Fins
- New York Presbyterian HospitalNew YorkNYUSA
- Division of Medical Ethics, Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - Wolfgang Ganglberger
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Katherine Hoffman
- Division of Biostatistics, Department of Population Health SciencesWeill Cornell Medical CollegeNew YorkNYUSA
| | - Aaron M. Mittel
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiaColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - David Roh
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Shibani S. Mukerji
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Caroline Der Nigoghossian
- New York Presbyterian HospitalNew YorkNYUSA
- Department of PharmacyNew York Presbyterian HospitalNew YorkNYUSA
| | - Soojin Park
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Edward J. Schenck
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineWeill Cornell Medical CollegeNew YorkNYUSA
| | - John Salazar‐Schicchi
- New York Presbyterian HospitalNew YorkNYUSA
- Department of MedicineColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
| | - Qi Shen
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Evan Sholle
- Information Technologies & Services DepartmentWeill Cornell MedicineNew YorkNYUSA
| | - Angela G. Velazquez
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
| | - Maria C. Walline
- New York Presbyterian HospitalNew YorkNYUSA
- Department of AnesthesiologyWeill Cornell Medical CollegeNew YorkNYUSA
| | - M. Brandon Westover
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Emery N. Brown
- Department of Brain and Cognitive ScienceInstitute of Medical Engineering and Sciences, the Picower Institute for Learning and Memory, and the Institute for Data Systems and Society, Massachusetts Institute of TechnologyBostonMAUSA
- Department of AnesthesiaCritical Care and Pain Medicine, Massachusetts General HospitalBostonMAUSA
| | - Jonathan Victor
- New York Presbyterian HospitalNew YorkNYUSA
- Department of NeurologyWeill Cornell Medical CollegeNew YorkNYUSA
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical CenterNew YorkNYUSA
| | - Brian L. Edlow
- Center for Neurotechnology and NeurorecoveryMassachusetts General HospitalBostonMAUSA
- Department of NeurologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | - Nicholas D. Schiff
- New York Presbyterian HospitalNew YorkNYUSA
- Department of NeurologyWeill Cornell Medical CollegeNew YorkNYUSA
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical CenterNew YorkNYUSA
| | - Jan Claassen
- Department of NeurologyColumbia University Irving Medical Center, Columbia UniversityNew YorkNYUSA
- New York Presbyterian HospitalNew YorkNYUSA
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Schenck EJ, Hoffman K, Goyal P, Choi J, Torres L, Rajwani K, Tam CW, Ivascu N, Martinez FJ, Berlin DA. Respiratory Mechanics and Gas Exchange in COVID-19-associated Respiratory Failure. Ann Am Thorac Soc 2020; 17:1158-1161. [PMID: 32432896 PMCID: PMC7462323 DOI: 10.1513/annalsats.202005-427rl] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Gentzler ER, Derry H, Ouyang DJ, Lief L, Berlin DA, Xu CJ, Maciejewski PK, Prigerson HG. Underdetection and Undertreatment of Dyspnea in Critically Ill Patients. Am J Respir Crit Care Med 2020; 199:1377-1384. [PMID: 30485121 DOI: 10.1164/rccm.201805-0996oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rationale: Dyspnea is a common and distressing physical symptom among patients in the ICU and may be underdetected and undertreated. Objectives: To determine the frequency of dyspnea relative to pain, the accuracy of nurses and personal caregiver dyspnea ratings relative to patient-reported dyspnea, and the relationship between nurse-detected dyspnea and treatment. Methods: This was an observational study of patients (n = 138) hospitalized in a medical ICU (MICU). Nurses and patients' personal caregivers at the bedside reported on their perception of patients' symptoms. Measurements and Main Results: Dyspnea was assessed by patients, caregivers, and nurses with a numerical rating scale. Across all three raters, the frequency of moderate to severe dyspnea was similar or greater than that of pain (P < 0.05 for caregiver and nurse ratings). Personal caregivers' ratings of dyspnea had substantial agreement with patient ratings (κ = 0.65, P < 0.001), but nurses' ratings were not significantly related to patient ratings (κ = 0.19, P = 0.39). Nurse detection of moderate to severe pain was significantly associated with opioid treatment (odds ratio, 2.70; 95% confidence interval, 1.10-6.60; P = 0.03); however, nurse detection of moderate to severe dyspnea was not significantly associated with any assessed treatment. Conclusions: Dyspnea was reported at least as frequently as pain among the sampled MICU patients. Personal caregivers had good agreement with patient reports of moderate to severe dyspnea. However, even when detected by nurses, dyspnea appeared to be undertreated. These findings suggest the need for improved detection and treatment of dyspnea in the MICU.
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Affiliation(s)
| | | | | | - Lindsay Lief
- 2 Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David A Berlin
- 2 Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | | | - Holly G Prigerson
- 1 Center for Research on End-Of-Life Care and.,2 Department of Medicine, Weill Cornell Medicine, New York, New York
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Ouyang DJ, Lief L, Russell D, Xu J, Berlin DA, Gentzler E, Su A, Cooper ZR, Senglaub SS, Maciejewski PK, Prigerson HG. Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes. PLoS One 2020; 15:e0227971. [PMID: 32069306 PMCID: PMC7028295 DOI: 10.1371/journal.pone.0227971] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 01/04/2020] [Indexed: 12/21/2022] Open
Abstract
Background The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses’ perceptions of patients’ distress and quality of death. Methods 200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women’s Hospital in Boston. Nurses were interviewed about their perceptions of the patients’ quality of death using validated measures. Patients were divided into 3 groups—no DNR, early DNR, late DNR placement during the patient’s final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient’s comorbidities, length of ICU stay, and procedures were also included in the model. Results 59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09–0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1–0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12–0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12–0.94]), controlling for non-beneficial procedures. Conclusions Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.
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Affiliation(s)
- Daniel J. Ouyang
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Lindsay Lief
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - David Russell
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Sociology, Appalachian State University, Boone, North Carolina, United State of America
| | - Jiehui Xu
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - David A. Berlin
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - Eliza Gentzler
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Amanda Su
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Zara R. Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Steven S. Senglaub
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Paul K. Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- Department of Radiology, Weill Cornell Medicine, New York, New York, United State of America
| | - Holly G. Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- * E-mail:
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Berlin DA, Manoach S, Heerdt PM. Response to letter by Drs. Bottinger and van der Hoorn. Intensive Care Med Exp 2019; 7:31. [PMID: 31172313 PMCID: PMC6554383 DOI: 10.1186/s40635-019-0258-x] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/22/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- David A Berlin
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10065, USA
| | - Seth Manoach
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10065, USA
| | - Paul M Heerdt
- Division of Applied Hemodnamics, Yale University School of Medicine, New Haven, USA.
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Chamberlin P, Lambden J, Kozlov E, Maciejewski R, Lief L, Berlin DA, Pelissier L, Yushuvayev E, Pan CX, Prigerson HG. Clinicians' Perceptions of Futile or Potentially Inappropriate Care and Associations with Avoidant Behaviors and Burnout. J Palliat Med 2019; 22:1039-1045. [PMID: 30874470 DOI: 10.1089/jpm.2018.0385] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Futile or potentially inappropriate care (futile/PIC) for dying inpatients leads to negative outcomes for patients and clinicians. In the setting of rising end-of-life health care costs and increasing physician burnout, it is important to understand the causes of futile/PIC, how it impacts on care and relates to burnout. Objectives: Examine causes of futile/PIC, determine whether clinicians report compensatory or avoidant behaviors as a result of such care and assess whether these behaviors are associated with burnout. Design: Online, cross-sectional questionnaire. Setting/Subjects: Clinicians at two academic hospitals in New York City. Methods: Respondents were asked the frequency with which they observed or provided futile/PIC and whether they demonstrated compensatory or avoidant behaviors as a result. A validated screen was used to assess burnout. Measurements: Descriptive statistics, odds ratios, linear regressions. Results: Surveys were completed by 349 subjects. A majority of clinicians (91.3%) felt they had provided or "possibly" provided futile/PIC in the past six months. The most frequent reason cited for PIC (61.0%) was the insistence of the patient's family. Both witnessing and providing PIC were statistically significantly (p < 0.05) associated with compensatory and avoidant behaviors, but more strongly associated with avoidant behaviors. Provision of PIC increased the likelihood of avoiding the patient's loved ones by a factor of 2.40 (1.82-3.19), avoiding the patient by a factor of 1.83 (1.32-2.55), and avoiding colleagues by a factor of 2.56 (1.57-4.20) (all p < 0.001). Avoiding the patient's loved ones (β = 0.55, SE = 0.12, p < 0.001), avoiding the patient (β = 0.38, SE = 0.17; p = 0.03), and avoiding colleagues (β = 0.78, SE = 0.28; p = 0.01) were significantly associated with burnout. Conclusions: Futile/PIC, provided or observed, is associated with avoidance of patients, families, and colleagues and those behaviors are associated with burnout.
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Affiliation(s)
- Peter Chamberlin
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
| | - Jason Lambden
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Elissa Kozlov
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Renee Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
| | - Lindsay Lief
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David A Berlin
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Latrice Pelissier
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Elina Yushuvayev
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Cynthia X Pan
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
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Karim HMR, Burns KEA, Ciobanu LD, El-Khatib M, Nicolini A, Vargas N, Hernández-Gilsoul T, Skoczyński S, Falcone VA, Arnal JM, Bach J, De Santo LS, Lucchini A, Steier J, Purro A, Petroianni A, Sassoon CS, Bambi S, Aguiar M, Soubani AO, Taniguchi C, Mollica C, Berlin DA, Piervincenzi E, Rao F, Luigi FS, Ferrari R, Garuti G, Laier-Groeneveld G, Fiorentino G, Ho KM, Alqahtani JS, Luján M, Moerer O, Resta O, Pierucci P, Papadakos P, Steiner S, Stieglitz S, Dikmen Y, Duan J, Bhakta P, Iglesias AU, Corcione N, Caldeira V, Karakurt Z, Valli G, Kondili E, Ruggieri MP, Raposo MS, Bottino F, Soler-González R, Gurjar M, Sandoval-Gutierrez JL, Jafari B, Arroyo-Cozar M, Noval AR, Corcione N, Barjaktarevic I, Sarc I, Mina B, Szkulmowski Z, Taniguchi C, Esquinas AM. Noninvasive ventilation: education and training. A narrative analysis and an international consensus document. Adv Respir Med 2019; 87:36-45. [PMID: 30830962 DOI: 10.5603/arm.a2019.0006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/22/2019] [Accepted: 02/05/2019] [Indexed: 11/25/2022]
Abstract
Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries.
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Affiliation(s)
- Habib Mohammad Reazaul Karim
- Department of Anesthesiology and Critical Care. All India Institute of Medical Sciences, Raipur, Great Eastern Road, Tatibandh, Raipur (CG)., 492099 Raipur, India
| | - Karen E A Burns
- Associate Professor, Clinician Scientist. Critical Care Medicine, Li Ka Shing Knowledge Insitute, St. Michael's Hospital,, 30 Bond Street, 4-045 Donnelly Wing. Toronto,, M5B 1W8 Ontario, Canada
| | - Laura D Ciobanu
- Assoc Professor, University of Medicine and Pharmacy, Romania, Romania
| | - Mohamad El-Khatib
- Department of Anesthesiology, American University of Beirut-Medical Center. School of Medicine,, Beirut-Lebanon, Lebanon
| | | | - Nicola Vargas
- Geriatric and Intensive Geriatric Cares,, Avelllino, Italy
| | - Thierry Hernández-Gilsoul
- Head of Emergency Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; Critical Care, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas., Mexico
| | - Szymon Skoczyński
- Department of Pneumonology, School of Medicine in Katowice, Medical University of Silesia,, Katowice, Poland
| | - Vito Antonio Falcone
- Department of Basic Medical Sciences, Neurosciences and Sense Organs - Section of Respiratory Disease, University of Bari Aldo Moro,, Bari, Italy
| | | | - John Bach
- Rutgers University New Jersey Medical School, New Jersey, United States
| | - Luca Salvatore De Santo
- Università della Campania Luigi Vanvitelli, Napoli and Cardiac Surgery Unit,, AORN dei Colli, Naples, Italy
| | - Alberto Lucchini
- General intensive care unit - San Gerardo Hospital, Milano-Bicocca University,, Milan, Italy
| | - Joerg Steier
- Professor of Respiratory and Sleep Medicine, King's College London, Faculty of Life Sciences and Medicine,, London, United Kingdom
| | - Andrea Purro
- Head of Intensive Care Unit, Humanitas Gradenigo Hospital., Turin, Italy
| | - Angelo Petroianni
- Respiratory Diseases Unit, Department of Cardiovascular and Respiratory Diseases, Policlinico Umberto I, Sapienza University of Rome,, Rome, Italy
| | - Catherine S Sassoon
- Professor of Medicine, Division of Pulmonary and Critical Care Medicine University of California, Irvine, CA,; VA Long Beach Healthcare System,, Long Beach, CA, United States
| | - Stefano Bambi
- Medical & Surgical Intensive Care Unit, Careggi University Hospital,, Florence, Italy
| | - Margarida Aguiar
- Pulmonologist, Pulmonary service, Hospital Beatriz Ângelo,, Loures, Portugal
| | - Ayman O Soubani
- Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine. Wayne State University School of Medicine, 3990 John R-3 Hudson, Detroit, MI, 48201, United States
| | - Corinne Taniguchi
- Physiotherapist Specialized in Intenvise Care and Pneumology- FMUSP/HCSão,, Paulo-SP, Brazil
| | | | - David A Berlin
- Department of Medicine, Weill Cornell Medicine New York, New York, United States
| | | | - Fabrizio Rao
- Respiratory Unit, Neuromuscular OmniCentre (NeMO), Neurorehabilitation, University of Milan, Niguarda Hospital,, Milan, Italy
| | | | - Rodolfo Ferrari
- Emergency Department, University Hospital Sant'Orsola, Malpighi,, Bologna, Italy
| | - Giancarlo Garuti
- Respiratory Unit, Santa Maria Bianca Hospital, Mirandola (MO),, ASL Modena, Modena, Italy
| | | | | | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital; School of Population & Global Health, University of Western Australia; and School of Veterinary & Life Sciences, Murdoch University., Perth, Australia
| | - Jaber Saud Alqahtani
- Department of Respiratory Care, Prince Sultan Military College of Health Sciences,, Dhahran, P.O. Box 33048, Dammam 31448, Saudi Arabia
| | - Manuel Luján
- Pneumology Service. Hospital of Sabadell, Universitat Autónoma de Barcelona., Sabadell, Spain
| | - Onnen Moerer
- Dept. of Anaesthesiology, Georg-August-University, University Medical Center Göttingen, Germany
| | - Onofrio Resta
- Cardiothoracic department, Respiratory and Sleep medicine Unit, Policlinic, Bari "Aldo Moro" University,, Italy
| | - Paola Pierucci
- Cardiothoracic department, Respiratory and Sleep medicine Unit, Policlinic, Bari "Aldo Moro" University,, Italy
| | - Peter Papadakos
- Department of Anesthesiology and Surgery. Director CCM. University of Rochester,, Rochester, New York, United States
| | - Stephan Steiner
- Departement of Cardiology, Pneumology and Intensive care, St Vincenz Hospital Limburg,, Limburg, Germany
| | - Sven Stieglitz
- Petrus Hospital Wuppertal, Academic Teaching Hospital of the University of Duesseldorf, Carnaper Str. 48, Clinic for Pneumology, Allergology, Sleep- and Intensive Care,, 42283 Wuppertal, Germany
| | - Yalim Dikmen
- Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Department of Intensive Care,, Fatih, Istanbul, Turkey
| | - Jun Duan
- Department of Respiratory Medicine, First Affiliated Hospital of Chongqing Medical University,, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Pradipta Bhakta
- Department of Anaesthesia and Intensive Care, University Hospital Limerick,, Dooradoyle, Limerick, Ireland
| | - Alejandro Ubeda Iglesias
- Intensive Care Unit, Hospital Punta de Europa, Algeciras Ctra, Getares,, s/n, 11207 Algeciras, Cádiz, Spain
| | - Nadia Corcione
- Departement of Anesthesia, Critical Care and Emergency. Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico., Milano, Italy
| | - Vânia Caldeira
- Pneumology Department, Hospital Santa Marta,, Lisboa, Portugal
| | - Zuhal Karakurt
- Assoc Prof, Pulmonary and Critical Care Department, Pulmonology and Intensivist, Dean in Hospital, University of Health Sciences,, Istanbul, Turkey
| | - Gabriele Valli
- Department of Emergency Medicine, San Giovanni Addolorata,, Rome, Italy
| | - Eumorfia Kondili
- Associate Professor of Intensive Care Medicine, Medical School , University of Crete Greece, ICU University Hospital of Heraklion,, Crete, Greece
| | - Maria Pia Ruggieri
- Direttore UOC PS-Breve Osservazione DEAI II livello AO San Giovanni Addolorata, Roma, Italy
| | - Margarida Simões Raposo
- Pulmonologist. Centro Hospitalar de Lisboa Ocidental Egas, Moniz Hospital,, Lisboa, Portugal
| | | | | | - Mohan Gurjar
- Department of Critical Care Medicine. Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS),, Rae Bareli Road, Lucknow (UP), 226014 Lucknow, India
| | | | - Behrouz Jafari
- Director, VALBHCS Sleep Program, Asst Professor of Medicine, Section of Pulmonary and Critical Care Medicine. University of California, Irvine. VA Long Beach Healthcare System 5901 East 7th Street (11/111P), Long Beach, CA, United States
| | | | - Ana Roca Noval
- Servicio de neumologia, Hospital Universitario La Princesa,, Madrid, Spain
| | - Nadia Corcione
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at University of California, Los Angeles, USA
| | - Irena Sarc
- Noninvasive ventilation department, University clinic for pulmonary and allergic diseases, Golnik, Slovenia
| | - Bushra Mina
- Department of Medicine, Pulmonary and Critical Care Medicine, Northwell Health, Lenox Hill Hospital, New York, NY USA
| | - Zbigniew Szkulmowski
- Departament of Anesthesia and ICU. University Hospital No 1 in Bydgoszcz. Collegium Medicum in Bydgoszcz. University Nicolaus Copernicus in Toruń. Bydgoszcz. Poland
| | | | - Antonio M Esquinas
- Intensive Care Unit. Hospital Morales Meseguer Murcia, Murcia, 30008, Spain.
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10
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Fredenburgh LE, Perrella MA, Barragan-Bradford D, Hess DR, Peters E, Welty-Wolf KE, Kraft BD, Harris RS, Maurer R, Nakahira K, Oromendia C, Davies JD, Higuera A, Schiffer KT, Englert JA, Dieffenbach PB, Berlin DA, Lagambina S, Bouthot M, Sullivan AI, Nuccio PF, Kone MT, Malik MJ, Porras MAP, Finkelsztein E, Winkler T, Hurwitz S, Serhan CN, Piantadosi CA, Baron RM, Thompson BT, Choi AM. A phase I trial of low-dose inhaled carbon monoxide in sepsis-induced ARDS. JCI Insight 2018; 3:124039. [PMID: 30518685 DOI: 10.1172/jci.insight.124039] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [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: 08/06/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a prevalent disease with significant mortality for which no effective pharmacologic therapy exists. Low-dose inhaled carbon monoxide (iCO) confers cytoprotection in preclinical models of sepsis and ARDS. METHODS We conducted a phase I dose escalation trial to assess feasibility and safety of low-dose iCO administration in patients with sepsis-induced ARDS. Twelve participants were randomized to iCO or placebo air 2:1 in two cohorts. Four subjects each were administered iCO (100 ppm in cohort 1 or 200 ppm in cohort 2) or placebo for 90 minutes for up to 5 consecutive days. Primary outcomes included the incidence of carboxyhemoglobin (COHb) level ≥10%, prespecified administration-associated adverse events (AEs), and severe adverse events (SAEs). Secondary endpoints included the accuracy of the Coburn-Forster-Kane (CFK) equation to predict COHb levels, biomarker levels, and clinical outcomes. RESULTS No participants exceeded a COHb level of 10%, and there were no administration-associated AEs or study-related SAEs. CO-treated participants had a significant increase in COHb (3.48% ± 0.7% [cohort 1]; 4.9% ± 0.28% [cohort 2]) compared with placebo-treated subjects (1.97% ± 0.39%). The CFK equation was highly accurate at predicting COHb levels, particularly in cohort 2 (R2 = 0.9205; P < 0.0001). Circulating mitochondrial DNA levels were reduced in iCO-treated participants compared with placebo-treated subjects. CONCLUSION Precise administration of low-dose iCO is feasible, well-tolerated, and appears to be safe in patients with sepsis-induced ARDS. Excellent agreement between predicted and observed COHb should ensure that COHb levels remain in the target range during future efficacy trials. TRIAL REGISTRATION ClinicalTrials.gov NCT02425579. FUNDING NIH grants P01HL108801, KL2TR002385, K08HL130557, and K08GM102695.
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Affiliation(s)
- Laura E Fredenburgh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark A Perrella
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Diana Barragan-Bradford
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dean R Hess
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elizabeth Peters
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Karen E Welty-Wolf
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Bryan D Kraft
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - R Scott Harris
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rie Maurer
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kiichi Nakahira
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Clara Oromendia
- Department of Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, New York, USA
| | - John D Davies
- Department of Respiratory Care, Duke University Medical Center, Durham, North Carolina, USA
| | - Angelica Higuera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kristen T Schiffer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Joshua A Englert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paul B Dieffenbach
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David A Berlin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Susan Lagambina
- Department of Respiratory Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark Bouthot
- Department of Respiratory Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew I Sullivan
- Department of Respiratory Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Paul F Nuccio
- Department of Respiratory Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mamary T Kone
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mona J Malik
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Maria Angelica Pabon Porras
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Eli Finkelsztein
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Tilo Winkler
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shelley Hurwitz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Charles N Serhan
- Center for Experimental Therapeutics and Reperfusion Injury, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Claude A Piantadosi
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Augustine Mk Choi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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11
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Schenck EJ, Oromendia C, Torres LK, Berlin DA, Choi AMK, Siempos II. Rapidly Improving ARDS in Therapeutic Randomized Controlled Trials. Chest 2018; 155:474-482. [PMID: 30359616 DOI: 10.1016/j.chest.2018.09.031] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/09/2018] [Accepted: 09/14/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Observational studies suggest that some patients meeting criteria for ARDS no longer fulfill the oxygenation criterion early in the course of their illness. This subphenotype of rapidly improving ARDS has not been well characterized. We attempted to assess the prevalence, characteristics, and outcomes of rapidly improving ARDS and to identify which variables are useful to predict it. METHODS A secondary analysis was performed of patient level data from six ARDS Network randomized controlled trials. We defined rapidly improving ARDS, contrasted with ARDS > 1 day, as extubation or a Pao2 to Fio2 ratio (Pao2:Fio2) > 300 on the first study day following enrollment. RESULTS The prevalence of rapidly improving ARDS was 10.5% (458 of 4,361 patients) and increased over time. Of the 1,909 patients enrolled in the three most recently published trials, 197 (10.3%) were extubated on the first study day, and 265 (13.9%) in total had rapidly improving ARDS. Patients with rapidly improving ARDS had lower baseline severity of illness and lower 60-day mortality (10.2% vs 26.3%; P < .0001) than ARDS > 1 day. Pao2:Fio2 at screening, change in Pao2:Fio2 from screening to enrollment, use of vasopressor agents, Fio2 at enrollment, and serum bilirubin levels were useful predictive variables. CONCLUSIONS Rapidly improving ARDS, mostly defined by early extubation, is an increasingly prevalent and distinct subphenotype, associated with better outcomes than ARDS > 1 day. Enrollment of patients with rapidly improving ARDS may negatively affect the prognostic enrichment and contribute to the failure of therapeutic trials.
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Affiliation(s)
- Edward J Schenck
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY
| | - Clara Oromendia
- Department of Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY
| | - Lisa K Torres
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY
| | - David A Berlin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY
| | - Augustine M K Choi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY
| | - Ilias I Siempos
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY; First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece.
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12
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DeSimone RA, Berlin DA, Avecilla ST, Goss CA. Investigational use of PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with hemorrhagic shock. Transfusion 2018; 58:2297-2300. [PMID: 30203845 DOI: 10.1111/trf.14799] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/29/2018] [Accepted: 04/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Jehovah's Witnesses pose a clinical challenge in the setting of critical anemia. Most do not accept transfusions, but some accept hemoglobin-based oxygen carriers on a compassionate-use basis. PEGylated carboxyhemoglobin bovine (PCHB) is an acellular dual-action carbon monoxide (CO)-releasing and oxygen transfer agent currently being investigated in Phase II clinical trials. CASE REPORT We present the case of a 42-year-old Jehovah's Witness with an acute upper gastrointestinal bleed and hemorrhagic shock who required emergent PCHB for stabilization during lifesaving interventions. After PCHB infusion, the patient's shock and encephalopathy improved with decreased vasopressor requirement. Through gastroenterology and interventional radiology procedures, the patient's bleeding stabilized. While receiving five additional doses of PCHB and other supportive therapies (iron, folate, vitamin B12, darbepoetin alfa), the patient was extubated and weaned off vasopressors. CONCLUSIONS PCHB was used to stabilize (bridge) a critically ill anemic patient for lifesaving interventions without adverse effects. Additional studies are warranted to explore the drug's safety profile and efficacy in patients declining blood products.
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Affiliation(s)
| | - David A Berlin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medicine
| | - Scott T Avecilla
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cheryl A Goss
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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13
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Lambden JP, Chamberlin P, Kozlov E, Lief L, Berlin DA, Pelissier LA, Yushuvayev E, Pan CX, Prigerson HG. Association of Perceived Futile or Potentially Inappropriate Care With Burnout and Thoughts of Quitting Among Health-Care Providers. Am J Hosp Palliat Care 2018; 36:200-206. [PMID: 30079753 DOI: 10.1177/1049909118792517] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Futile or potentially inappropriate care (futile/PIC) has been suggested as a factor contributing to clinician well-being; however, little is known about this association. OBJECTIVE To determine whether futile/PIC provision is associated with measures of clinician well-being. DESIGN Cross-sectional, self-administered, online questionnaire. SETTING Two New York City Hospitals. PARTICIPANTS Attending physicians, residents, nurses, and physician assistants in the fields of internal medicine, surgery, neurology, or intensive care. EXPOSURE(S) Provision of perceived futile/PIC. MEASUREMENTS Main outcomes included (1) clinician burnout, measured using the Physician Worklife Study screen; (2) clinician depression, measured using the Patient Health Questionnaire; and (3) intention to quit, measured using questions assessing thoughts of quitting and how seriously it is being considered. RESULTS Of 1784 clinicians who received surveys, 349 participated. Across all clinicians, 91% reported that they either had or had possibly provided futile/PIC to a patient. Overall, 43.4% of clinicians screened positive for burnout syndrome, 7.8% screened positive for depression, and 35.5% reported thoughts of leaving their job as a result of futile/PIC. The amount of perceived futile/PIC provided was associated with burnout (odds ratio [OR] 3.8 [16-30 patients vs 1-2 patients]; 95% confidence interval [CI]: 1.1-12.8) and having thoughts of quitting (OR, 7.4 [16-30 patients vs 1-2 patients]; 95% CI: 2.0-27), independent of depression, position, department, and the number of dying patients cared for. CONCLUSIONS A large majority of clinicians report providing futile/PIC, and such care is associated with measures of clinician well-being, including burnout and intention to quit.
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Affiliation(s)
- Jason P Lambden
- Center for Research on End-Of-Life Care, Weill Cornell Medicine, NY, USA.,Department of Medicine, Weill Cornell Medicine, NY, USA
| | - Peter Chamberlin
- Center for Research on End-Of-Life Care, Weill Cornell Medicine, NY, USA.,Department of Medicine, Weill Cornell Medicine, NY, USA
| | - Elissa Kozlov
- Center for Research on End-Of-Life Care, Weill Cornell Medicine, NY, USA.,Department of Medicine, Weill Cornell Medicine, NY, USA
| | - Lindsay Lief
- Department of Medicine, Weill Cornell Medicine, NY, USA
| | | | - Latrice A Pelissier
- Division of Geriatrics and Palliative Care Medicine, NewYork-Presbyterian /Queens, NY, USA
| | - Elina Yushuvayev
- Division of Geriatrics and Palliative Care Medicine, NewYork-Presbyterian /Queens, NY, USA
| | - Cynthia X Pan
- Division of Geriatrics and Palliative Care Medicine, NewYork-Presbyterian /Queens, NY, USA
| | - Holly G Prigerson
- Center for Research on End-Of-Life Care, Weill Cornell Medicine, NY, USA.,Department of Medicine, Weill Cornell Medicine, NY, USA
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14
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Barjaktarevic I, Esquinas AM, Johannes J, Berlin DA. Preoxygenation With High-Flow Nasal Cannula: Benefits of Its Extended Use During the Process of Intubation. Respir Care 2017; 62:390. [PMID: 28246287 DOI: 10.4187/respcare.05125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine David Geffen School of Medicine UCLA Los Angeles, California
| | | | - James Johannes
- Division of Pulmonary and Critical Care Medicine David Geffen School of Medicine UCLA Los Angeles, California
| | - David A Berlin
- Division of Pulmonary and Critical Care Medicine Weill Cornell Medical College Cornell University New York, New York
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15
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Luo M, Flood EC, Almeida D, Yan L, Berlin DA, Heerdt PM, Hajjar KA. Annexin A2 supports pulmonary microvascular integrity by linking vascular endothelial cadherin and protein tyrosine phosphatases. J Exp Med 2017; 214:2535-2545. [PMID: 28694388 PMCID: PMC5584111 DOI: 10.1084/jem.20160652] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 03/14/2017] [Accepted: 05/31/2017] [Indexed: 12/11/2022] Open
Abstract
Luo et al. demonstrate that annexin A2 is required to maintain vascular integrity in the hypoxic mouse lung. A2 prevents extravasation of fluid and leukocytes by promoting activity of the phosphatases VE-PTP and SHP2, thereby modulating phosphorylation of vascular endothelial cadherin. Relative or absolute hypoxia activates signaling pathways that alter gene expression and stabilize the pulmonary microvasculature. Alveolar hypoxia occurs in disorders ranging from altitude sickness to airway obstruction, apnea, and atelectasis. Here, we report that the phospholipid-binding protein, annexin A2 (ANXA2) functions to maintain vascular integrity in the face of alveolar hypoxia. We demonstrate that microvascular endothelial cells (ECs) from Anxa2−/− mice display reduced barrier function and excessive Src-related tyrosine phosphorylation of the adherens junction protein vascular endothelial cadherin (VEC). Moreover, unlike Anxa2+/+ controls, Anxa2−/− mice develop pulmonary edema and neutrophil infiltration in the lung parenchyma in response to subacute alveolar hypoxia. Mice deficient in the ANXA2-binding partner, S100A10, failed to demonstrate hypoxia-induced pulmonary edema under the same conditions. Further analyses reveal that ANXA2 forms a complex with VEC and its phosphatases, EC-specific protein tyrosine phosphatase (VE-PTP) and Src homology phosphatase 2 (SHP2), both of which are implicated in vascular integrity. In the absence of ANXA2, VEC is hyperphosphorylated at tyrosine 731 in response to vascular endothelial growth factor, which likely contributes to hypoxia-induced extravasation of fluid and leukocytes. We conclude that ANXA2 contributes to pulmonary microvascular integrity by enabling VEC-related phosphatase activity, thereby preventing vascular leak during alveolar hypoxia.
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Affiliation(s)
- Min Luo
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Elle C Flood
- Department of Cell and Developmental Biology, Weill Cornell Medical College, New York, NY
| | - Dena Almeida
- Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - LunBiao Yan
- Department of Cell and Developmental Biology, Weill Cornell Medical College, New York, NY
| | - David A Berlin
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Paul M Heerdt
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY
| | - Katherine A Hajjar
- Department of Pediatrics, Weill Cornell Medical College, New York, NY .,Department of Cell and Developmental Biology, Weill Cornell Medical College, New York, NY.,Department of Medicine, Weill Cornell Medical College, New York, NY
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16
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Finkelsztein EJ, Jones DS, Ma KC, Pabón MA, Delgado T, Nakahira K, Arbo JE, Berlin DA, Schenck EJ, Choi AMK, Siempos II. Comparison of qSOFA and SIRS for predicting adverse outcomes of patients with suspicion of sepsis outside the intensive care unit. Crit Care 2017; 21:73. [PMID: 28342442 PMCID: PMC5366240 DOI: 10.1186/s13054-017-1658-5] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/28/2017] [Indexed: 01/05/2023]
Abstract
Background The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) Task Force recently introduced a new clinical score termed quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) for identification of patients at risk of sepsis outside the intensive care unit (ICU). We attempted to compare the discriminatory capacity of the qSOFA versus the Systemic Inflammatory Response Syndrome (SIRS) score for predicting mortality, ICU-free days, and organ dysfunction-free days in patients with suspicion of infection outside the ICU. Methods The Weill Cornell Medicine Registry and Biobank of Critically Ill Patients is an ongoing cohort of critically ill patients, for whom biological samples and clinical information (including vital signs before and during ICU hospitalization) are prospectively collected. Using such information, qSOFA and SIRS scores outside the ICU (specifically, within 8 hours before ICU admission) were calculated. This study population was therefore comprised of patients in the emergency department or the hospital wards who had suspected infection, were subsequently admitted to the medical ICU and were included in the Registry and Biobank. Results One hundred fifty-two patients (67% from the emergency department) were included in this study. Sixty-seven percent had positive cultures and 19% died in the hospital. Discrimination of in-hospital mortality using qSOFA [area under the receiver operating characteristic curve (AUC), 0.74; 95% confidence intervals (CI), 0.66–0.81] was significantly greater compared with SIRS criteria (AUC, 0.59; 95% CI, 0.51–0.67; p = 0.03). The qSOFA performed better than SIRS regarding discrimination for ICU-free days (p = 0.04), but not for ventilator-free days (p = 0.19), any organ dysfunction-free days (p = 0.13), or renal dysfunction-free days (p = 0.17). Conclusions In patients with suspected infection who eventually required admission to the ICU, qSOFA calculated before their ICU admission had greater accuracy than SIRS for predicting mortality and ICU-free days. However, it may be less clear whether qSOFA is also better than SIRS criteria for predicting ventilator free-days and organ dysfunction-free days. These findings may help clinicians gain further insight into the usefulness of qSOFA. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1658-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eli J Finkelsztein
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Daniel S Jones
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Kevin C Ma
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Maria A Pabón
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Tatiana Delgado
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Kiichi Nakahira
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - John E Arbo
- Department of Medicine, Division of Emergency Medicine and Pulmonary Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - David A Berlin
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Edward J Schenck
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Augustine M K Choi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA
| | - Ilias I Siempos
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, New York, NY, USA. .,First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece. .,New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10065, USA.
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17
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Ma KC, Chung A, Aronson KI, Krishnan JK, Barjaktarevic IZ, Berlin DA, Schenck EJ. Bronchoscopic intubation is an effective airway strategy in critically ill patients. J Crit Care 2016; 38:92-96. [PMID: 27875775 DOI: 10.1016/j.jcrc.2016.10.022] [Citation(s) in RCA: 8] [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: 06/28/2016] [Revised: 09/21/2016] [Accepted: 10/31/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE American Society of Anesthesiologists guidelines recommend the use of bronchoscopic intubation as a rescue technique in critically ill patients. We sought to assess the safety and efficacy of bronchoscopic intubation as an initial approach in critically ill patients. METHODS We performed a retrospective cohort study of patients who underwent endotracheal intubation in the medical intensive care unit of a tertiary urban referral center over 1 academic year. The primary outcome was first-pass success rate. MEASUREMENTS AND MAIN RESULTS We identified 219 patients who underwent either bronchoscopic (n=52) or laryngoscopic guided (n=167) intubation as the initial attempt. There was a higher first-pass success rate in the bronchoscopic intubation group than in the laryngoscopic group (96% vs 78%; P=.003). The bronchoscopic intubation group had a higher body mass index (28.4 vs 25.9; P=.027) and higher preintubation fraction of inspired oxygen requirement (0.73±0.27 vs 0.63±0.30; P=.044) than the laryngoscopic group. There were no cases of right mainstem intubation, esophageal intubation, or pneumothorax with bronchoscopic intubation. Rates of postintubation hypotension and hypoxemia were similar in both groups. The association with first-pass success remained with multivariate and propensity matched analysis. CONCLUSIONS Bronchoscopic intubation as an initial strategy in critically ill patients is associated with a higher first-pass success rate than laryngoscopic intubation, and is not associated with an increase in complications.
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Affiliation(s)
- Kevin C Ma
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York
| | - Augustine Chung
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine UCLA, Los Angeles
| | - Kerri I Aronson
- Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York
| | - Jamuna K Krishnan
- Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York
| | - Igor Z Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine UCLA, Los Angeles
| | - David A Berlin
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York
| | - Edward J Schenck
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York.
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Abstract
In 2001, Rivers and colleagues published a randomized controlled trial of early goal-directed therapy (EGDT) for the treatment of sepsis. More than a decade later, it remains a landmark achievement. The study proved the benefits of early aggressive treatment of sepsis. However, many questions remain about specific aspects of the complex EGDT algorithm. Recently, 3 large trials attempted to replicate these results. None of the studies demonstrated a benefit of an EGDT protocol for sepsis. This review explores the physiologic basis of goal-directed therapy, including the hemodynamic targets and the therapeutic interventions. An understanding of the physiologic basis of EGDT helps reconcile the results of the clinical trials.
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Affiliation(s)
- Lindsay Lief
- 1 Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - John Arbo
- 2 Division of Emergency Medicine, Weill Cornell Medicine, New York, NY, USA
| | - David A Berlin
- 1 Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
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Affiliation(s)
- Ilias I Siempos
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David A Berlin
- Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, New York
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Prigerson HG, Bao Y, Shah MA, Paulk ME, LeBlanc TW, Schneider BJ, Garrido MM, Reid MC, Berlin DA, Adelson KB, Neugut AI, Maciejewski PK. Chemotherapy Use, Performance Status, and Quality of Life at the End of Life. JAMA Oncol 2016. [PMID: 26203912 DOI: 10.1001/jamaoncol.2015.2378] [Citation(s) in RCA: 377] [Impact Index Per Article: 47.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Although many patients with end-stage cancer are offered chemotherapy to improve quality of life (QOL), the association between chemotherapy and QOL amid progressive metastatic disease has not been well-studied. American Society for Clinical Oncology guidelines recommend palliative chemotherapy only for solid tumor patients with good performance status. OBJECTIVE To evaluate the association between chemotherapy use and QOL near death (QOD) as a function of patients' performance status. DESIGN, SETTING, AND PARTICIPANTS A multi-institutional, longitudinal cohort study of patients with end-stage cancer recruited between September 2002 and February 2008. Chemotherapy use (n = 158 [50.6%]) and Eastern Cooperative Oncology Group (ECOG) performance status were assessed at baseline (median = 3.8 months before death) and patients with progressive metastatic cancer (N = 312) following at least 1 chemotherapy regimen were followed prospectively until death at 6 outpatient oncology clinics in the United States. MAIN OUTCOMES AND MEASURES Patient QOD was determined using validated caregiver ratings of patients' physical and mental distress in their final week. RESULTS Chemotherapy use was not associated with patient survival controlling for clinical setting and patients' performance status. Among patients with good (ECOG score = 1) baseline performance status, chemotherapy use compared with nonuse was associated with worse QOD (odds ratio [OR], 0.35; 95% CI, 0.17-0.75; P = .01). Baseline chemotherapy use was not associated with QOD among patients with moderate (ECOG score = 2) baseline performance status (OR, 1.06; 95% CI, 0.51-2.21; P = .87) or poor (ECOG score = 3) baseline performance status (OR, 1.34; 95% CI, 0.46-3.89; P = .59). CONCLUSIONS AND RELEVANCE Although palliative chemotherapy is used to improve QOL for patients with end-stage cancer, its use did not improve QOD for patients with moderate or poor performance status and worsened QOD for patients with good performance status. The QOD in patients with end-stage cancer is not improved, and can be harmed, by chemotherapy use near death, even in patients with good performance status.
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Affiliation(s)
- Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medical College, New York, New York2Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Yuhua Bao
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Manish A Shah
- Meyer Cancer Center of Weill Cornell Medical College, Medical Oncology/Solid Tumor Program, New York, New York
| | - M Elizabeth Paulk
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Melissa M Garrido
- James J. Peters VA Medical Center, Bronx, New York9Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - David A Berlin
- Department of Medicine, Medical Intensive Care Unit, New York Presbyterian Hospital-Weill Cornell Center, New York
| | - Kerin B Adelson
- Smilow Cancer Hospital at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut
| | - Alfred I Neugut
- Department of Medicine and Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, New York12Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Paul K Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medical College, New York, New York14Department of Radiology, Weill Cornell Medical College, New York, New York
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Abstract
Recent studies challenge the utility of central venous pressure monitoring as a surrogate for cardiac preload. Starting with Starling’s original studies on the regulation of cardiac output, this review traces the history of the experiments that elucidated the role of central venous pressure in circulatory physiology. Central venous pressure is an important physiologic parameter, but it is not an independent variable that determines cardiac output.
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Affiliation(s)
- David A Berlin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, 1300 York Avenue, New York, NY, 10021, USA.
| | - Jan Bakker
- Erasmus MC University Medical Center Rotterdam, PO Box 2040 - Room H 625, Rotterdam, 3000 CA, the Netherlands.
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Affiliation(s)
- David A Berlin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, 1300 York Avenue, 10021, New York, NY, USA,
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Berlin DA. Thrombolytic therapy in patients with submassive pulmonary embolism. N Engl J Med 2003; 348:357-9; author reply 357-9. [PMID: 12542062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
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Berlin DA. Mental health in and out of public health. Ment Hyg 1970; 54:288-94. [PMID: 4315496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Berlin DA. Evaluation of a mental health information and referral service. Community Ment Health J 1970; 6:144-54. [PMID: 5520457 DOI: 10.1007/bf01434660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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