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Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024: Executive Summary. Crit Care Med 2024; 52:649-655. [PMID: 38240482 DOI: 10.1097/ccm.0000000000006173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- GUIDE Canada, McMaster University, Hamilton, ON, Canada
| | - Michael Sirimaturos
- System Critical Care Pharmacy Services Leader, Houston Methodist Hospital, Houston, TX
| | - Eliotte L Hirshberg
- Adult and Pediatric Critical Care Specialist, University of Utah School of Medicine, Salt Lake City, UT
| | - Nicholas G Bircher
- Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Michael S D Agus
- Harvard Medical School and Division Chief, Medical Critical Care, Boston Children's Hospital, Boston, MA
| | | | | | | | - Amado X Freire
- Pulmonary Critical Care and Sleep Medicine at the University of Tennessee Health Science Center, Memphis, TN
| | | | - Sharon Y Irving
- Department of Nursing and Clinical Care Services-Critical Care, University of Pennsylvania School of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James S Krinsley
- Director of Critical Care, Emeritus, Vagelos Columbia University College of Physicians and Surgeons, Stamford Hospital, Stamford, CT
| | - Michael J Lanspa
- Division of Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Micah T Long
- Department of Anesthesiology, Division of Critical Care, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - David Nagpal
- Division of Cardiac Surgery, Critical Care Western, London Health Sciences Centre, London, ON, Canada
| | - Jean-Charles Preiser
- Medical Director for Research and Teaching, Erasme Hospital, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024. Crit Care Med 2024; 52:e161-e181. [PMID: 38240484 DOI: 10.1097/ccm.0000000000006174] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
RATIONALE Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods. OBJECTIVES The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians. PANEL DESIGN The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the guidelines, including panel selection and voting. METHODS We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42 wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, "In our practice" statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research. RESULTS This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two "In our practice" statements, and one research statement), with additional detail on specific subset populations where available. CONCLUSIONS The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient's existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- GUIDE Canada, McMaster University, Hamilton, ON, Canada
| | - Michael Sirimaturos
- System Critical Care Pharmacy Services Leader, Houston Methodist Hospital, Houston, TX
| | - Eliotte L Hirshberg
- Adult and Pediatric Critical Care Specialist, University of Utah School of Medicine, Salt Lake City, UT
| | - Nicholas G Bircher
- Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Michael S D Agus
- Harvard Medical School and Division Chief, Medical Critical Care, Boston Children's Hospital, Boston, MA
| | | | | | | | - Amado X Freire
- Pulmonary Critical Care and Sleep Medicine at the University of Tennessee Health Science Center, Memphis, TN
| | | | - Sharon Y Irving
- Department of Nursing and Clinical Care Services-Critical Care, University of Pennsylvania School of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James S Krinsley
- Director of Critical Care, Emeritus, Vagelos Columbia University College of Physicians and Surgeons, Stamford Hospital, Stamford, CT
| | - Michael J Lanspa
- Division of Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Micah T Long
- Department of Anesthesiology, Division of Critical Care, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - David Nagpal
- Division of Cardiac Surgery, Critical Care Western, London Health Sciences Centre, London, ON, Canada
| | - Jean-Charles Preiser
- Medical Director for Research and Teaching, Erasme Hospital, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Harris BRE, Butler A, Hirshberg EL, Hopkins RO, Butler J, Orme J, Brown SM, Beesley SJ. Trainees' Experience of Family Presence during Intensive Care Unit Procedures. ATS Sch 2023; 4:469-473. [PMID: 38196675 PMCID: PMC10773269 DOI: 10.34197/ats-scholar.2023-0065br] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/17/2023] [Indexed: 01/11/2024] Open
Affiliation(s)
| | | | - Eliotte L. Hirshberg
- Pulmonary Division, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Center for Humanizing Critical Care, Intermountain Healthcare, Salt Lake City, Utah
- Pulmonary Division, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
| | - Ramona O. Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Salt Lake City, Utah
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah
| | - Jorie Butler
- Center for Humanizing Critical Care, Intermountain Healthcare, Salt Lake City, Utah
- Geriatrics Division, Department of Internal Medicine, and
- Department of Psychology, University of Utah, Salt Lake City, Utah
| | - James Orme
- Pulmonary Division, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Center for Humanizing Critical Care, Intermountain Healthcare, Salt Lake City, Utah
- Pulmonary Division, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
| | - Samuel M. Brown
- Pulmonary Division, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Center for Humanizing Critical Care, Intermountain Healthcare, Salt Lake City, Utah
- Pulmonary Division, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
| | - Sarah J. Beesley
- Pulmonary Division, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Center for Humanizing Critical Care, Intermountain Healthcare, Salt Lake City, Utah
- Pulmonary Division, Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
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Hendrickson KW, Hopkins RO, Groat DL, Stokes SC, Schroeder FM, Butler JM, Hirshberg EL. Patient experiences with SARS-CoV-2: Associations between patient experience of disease and coping profiles. PLoS One 2023; 18:e0294201. [PMID: 37983278 PMCID: PMC10659202 DOI: 10.1371/journal.pone.0294201] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 10/27/2023] [Indexed: 11/22/2023] Open
Abstract
INTRODUCTION Severe acute respiratory syndrome coronavirus 2, (SARS-CoV-2,) caused an influx of patients with acute disease characterized by a variety of symptoms termed COVID-19 disease, with some patients going on to develop post-acute COVID-19 syndrome. Individual factors like sex or coping styles are associated with a person's disease experience and quality of life. Individual differences in coping styles used to manage COVID-19 related stress correlate with physical and mental health outcomes. Our study sought to understand the relationship between COVID-19 symptoms, severity of acute disease, and coping profiles. METHODS An online survey to assess symptoms, functional status, and recovery in a large group of patients was nationally distributed online. The survey asked about symptoms, course of illness, and included the Brief-COPE and the adapted Social Relationship Inventory. We used descriptive and cluster analyses to characterize patterns of survey responses. RESULTS 976 patients were included in the analysis. The most common symptoms reported by the patients were fatigue (72%), cough (71%), body aches/joint pain (66%), headache (62%), and fever/chills (62%). 284 participants reported PACS. We described three different coping profiles: outward, inward, and dynamic copers. DISCUSSION Fatigue, cough, and body aches/joint pains were the most frequently reported symptoms. PACS patients were sicker, more likely to have been hospitalized. Of the three coping profiles, outward copers were more likely to be admitted to the hospital and had the healthiest coping strategies. Dynamic copers activated several coping strategies both positive and negative; they were also younger and more likely to report PACS. CONCLUSION Cough, fatigue, and body aches/joint pain are common and most important to patients with acute COVID-19, while shortness of breath defined the experience for patients with PACS. Of the three coping profiles, dynamic copers were more likely to report PACS. Additional investigations into coping profiles in general, and the experience of COVID-19 and PACS is needed.
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Affiliation(s)
- Kathryn W. Hendrickson
- The Oregon Clinic, Department of Pulmonary, Critical Care, and Sleep Medicine East, Portland, Oregon, United States of America
| | - Ramona O. Hopkins
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, United States of America
- Intermountain Health, Center for Humanizing Critical Care, Murray, Utah, United States of America
| | - Danielle L. Groat
- Intermountain Health, Center for Humanizing Critical Care, Murray, Utah, United States of America
- Intermountain Health, Division of Pulmonary and Critical Care, Murray, Utah, United States of America
| | - Stephanie C. Stokes
- Intermountain Health, Strategic Research, Salt Lake City, Utah, United States of America
| | - Fiona M. Schroeder
- Intermountain Health, Strategic Research, Salt Lake City, Utah, United States of America
| | - Jorie M. Butler
- Intermountain Health, Center for Humanizing Critical Care, Murray, Utah, United States of America
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States of America
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Informatics Decision-Enhancement and Analytic Sciences (IDEAS), Center for Innovation & Geriatrics Research, Education, and Clinical Center (GRECC), VA Salt Lake City Health Care System, Salt Lake City, UT, United States of America
| | - Eliotte L. Hirshberg
- Intermountain Health, Center for Humanizing Critical Care, Murray, Utah, United States of America
- Intermountain Health, Division of Pulmonary and Critical Care, Murray, Utah, United States of America
- Division of Pulmonology, School of Medicine, University of Utah, Salt Lake City, Utah, United States of America
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Lanspa MJ, Dugar SP, Prigmore HL, Boyd JS, Rupp JD, Lindsell CJ, Rice TW, Qadir N, Lim GW, Shiloh AL, Dieiev V, Gong MN, Fox SW, Hirshberg EL, Khan A, Kornfield J, Schoeneck JH, Macklin N, Files DC, Gibbs KW, Prekker ME, Parsons-Moss D, Bown M, Olsen TD, Knox DB, Cirulis MM, Mehkri O, Duggal A, Tenforde MW, Patel MM, Self WH, Brown SM. Early Serial Echocardiographic and Ultrasonographic Findings in Critically Ill Patients With COVID-19. CHEST Crit Care 2023; 1:100002. [PMID: 38014378 PMCID: PMC10030437 DOI: 10.1016/j.chstcc.2023.100002] [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] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Background Cardiac function of critically ill patients with COVID-19 generally has been reported from clinically obtained data. Echocardiographic deformation imaging can identify ventricular dysfunction missed by traditional echocardiographic assessment. Research Question What is the prevalence of ventricular dysfunction and what are its implications for the natural history of critical COVID-19? Study Design and Methods This is a multicenter prospective cohort of critically ill patients with COVID-19. We performed serial echocardiography and lower extremity vascular ultrasound on hospitalization days 1, 3, and 8. We defined left ventricular (LV) dysfunction as the absolute value of longitudinal strain of < 17% or left ventricle ejection fraction (LVEF) of < 50%. Primary clinical outcome was inpatient survival. Results We enrolled 110 patients. Thirty-nine (35.5%) died before hospital discharge. LV dysfunction was present at admission in 38 patients (34.5%) and in 21 patients (36.2%) on day 8 (P = .59). Median baseline LVEF was 62% (interquartile range [IQR], 52%-69%), whereas median absolute value of baseline LV strain was 16% (IQR, 14%-19%). Survivors and nonsurvivors did not differ statistically significantly with respect to day 1 LV strain (17.9% vs 14.4%; P = .12) or day 1 LVEF (60.5% vs 65%; P = .06). Nonsurvivors showed worse day 1 right ventricle (RV) strain than survivors (16.3% vs 21.2%; P = .04). Interpretation Among patients with critical COVID-19, LV and RV dysfunction is common, frequently identified only through deformation imaging, and early (day 1) RV dysfunction may be associated with clinical outcome.
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Affiliation(s)
- Michael J Lanspa
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | | | | | - Jeremy S Boyd
- Vanderbilt Health, Vanderbilt University, Nashville, TN
| | - Jordan D Rupp
- Vanderbilt Health, Vanderbilt University, Nashville, TN
| | | | - Todd W Rice
- Vanderbilt Comprehensive Care Clinic, Nashville, TN
| | - Nida Qadir
- University of California, Los Angeles, Los Angeles, CA
| | - George W Lim
- University of California, Los Angeles, Los Angeles, CA
| | | | | | | | | | | | - Akram Khan
- Oregon Health and Science University, Portland, OR
| | | | | | | | | | | | | | | | - Mikaele Bown
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | - Troy D Olsen
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | - Daniel B Knox
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | - Meghan M Cirulis
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
| | | | | | | | | | | | - Samuel M Brown
- Shock Trauma ICU, Intermountain Medical Center, Salt Lake City, UT
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Ettinger NA, Hill VL, Russ CM, Rakoczy KJ, Fallat ME, Wright TN, Choong K, Agus MSD, Hsu B, Mack E, Day S, Lowrie L, Siegel L, Srinivasan V, Gadepalli S, Hirshberg EL, Kissoon N, October T, Tamburro RF, Rotta A, Tellez S, Rauch DA, Ernst K, Vinocur C, Lam VT, Romito B, Hanson N, Gigli KH, Mauro M, Leonard MS, Alexander SN, Davidoff A, Besner GE, Browne M, Downard CD, Gow KW, Islam S, Saunders Walsh D, Williams RF, Thorne V. Guidance for Structuring a Pediatric Intermediate Care Unit. Pediatrics 2022; 149:186777. [PMID: 35490284 DOI: 10.1542/peds.2022-057009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.
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Affiliation(s)
- Nicholas A Ettinger
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Vanessa L Hill
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine/The Children's Hospital of San Antonio, San Antonio, Texas
| | - Christiana M Russ
- Intermediate Care Program.,Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine J Rakoczy
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Tuft's Children's Hospital, Boston, Massachusetts
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Karen Choong
- Division of Critical Care, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Michael S D Agus
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Benson Hsu
- Division of Critical Care, Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
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Dahmer MK, Yang G, Zhang M, Quasney MW, Sapru A, Weeks HM, Sinha P, Curley MAQ, Delucchi KL, Calfee CS, Flori H, Matthay MA, Bateman ST, Berg MD, Borasino S, Bysani GK, Cowl AS, Bowens CD, Faustino VS, Fineman LD, Godshall AJ, Hirshberg EL, Kirby AL, McLaughlin GE, Medar SS, Oren PP, Schneider JB, Schwarz AJ, Shanley TP, Source LR, Truemper EJ, Vender Heyden MA, Wittmayer K, Zuppa AF, Wypij D. Identification of phenotypes in paediatric patients with acute respiratory distress syndrome: a latent class analysis. Lancet Respir Med 2022; 10:289-297. [PMID: 34883088 PMCID: PMC8897230 DOI: 10.1016/s2213-2600(21)00382-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/04/2021] [Accepted: 08/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Previous latent class analysis of adults with acute respiratory distress syndrome (ARDS) identified two phenotypes, distinguished by the degree of inflammation. We aimed to identify phenotypes in children with ARDS in whom developmental differences might be important, using a latent class analysis approach similar to that used in adults. METHODS This study was a secondary analysis of data aggregated from the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial and the Genetic Variation and Biomarkers in Children with Acute Lung Injury (BALI) ancillary study. We used latent class analysis, which included demographic, clinical, and plasma biomarker variables, to identify paediatric ARDS (PARDS) phenotypes within a cohort of children included in the RESTORE and BALI studies. The association of phenotypes with clinically relevant outcomes and the performance of paediatric data in adult ARDS classification algorithms were also assessed. FINDINGS 304 children with PARDS were included in this secondary analysis. Using latent class analysis, a two-class model was a better fit for the cohort than a one-class model (p<0·001). Latent class analysis identified two classes: class 1 (181 [60%] of 304 patients with PARDS) and class 2 (123 [40%] of 304 patients with PARDS), referred to as phenotype 1 and 2 hereafter. Phenotype 2 was characterised by higher concentrations of inflammatory biomarkers, a higher incidence of vasopressor use, and more frequent diagnosis of sepsis, consistent with the adult hyperinflammatory phenotype. All levels of severity of PARDS were observed across both phenotypes. Children with the hyperinflammatory phenotype (phenotype 2) had worse clinical outcomes than those with the hypoinflammatory phenotype (phenotype 1), with a longer duration of mechanical ventilation (median 10·0 days [IQR 6·3-21·0] for phenotype 2 vs 6·6 days [4·1-10·8] for phenotype 1, p<0·0001), and higher incidence of mortality (17 [13·8%] of 123 patients vs four [2·2%] of 181 patients, p=0·0001). When using adult phenotype classification algorithms in children, the soluble tumour necrosis factor receptor-1 (sTNFr1), vasopressor use, and interleukin (IL)-6 variables gave an area under the curve (AUC) of 0·956, and the sTNFr1, vasopressor use, and IL-8 variables gave an AUC of 0·954, compared with the gold standard of latent class analysis. INTERPRETATION Latent class analysis identified two phenotypes in children with ARDS with characteristics similar to those in adults, including worse outcomes among patients with the hyperinflammatory phenotype. PARDS phenotypes should be considered in design and analysis of future clinical trials in children. FUNDING US National Institutes of Health.
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Affiliation(s)
- Mary K Dahmer
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Guangyu Yang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Michael W Quasney
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Anil Sapru
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA
| | - Heidi M. Weeks
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Pratik Sinha
- Department of Anesthesia, Washington University, St. Louis, MO
| | - Martha AQ Curley
- Department of Family and Community Health (School of Nursing), Division of Anesthesia and Critical Care Medicine (Perelman School of Medicine) University of Pennsylvania, Philadelphia, PA; Research Institute; Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kevin L Delucchi
- Department of Psychiatry & Behavioral Sciences, University of California, San Francisco, San Francisco, CA
| | - Carolyn S Calfee
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, CA
| | - Heidi Flori
- Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI
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Knox DB, Hirshberg EL, Orme J, Peltan I, Lanspa MJ. Effect of COVID 19 pneumonia on hyperglycemia: Is it different from non COVID pneumonia? Diabetes Metab Syndr 2022; 16:102407. [PMID: 35074624 PMCID: PMC8767985 DOI: 10.1016/j.dsx.2022.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Glycemic control in critical illness has been linked to outcomes. We sought to investigate if COVID pneumonia was causing disrupted glycemic control compared to historically similar diseases. METHODS At Intermountain Healthcare, a 23-hospital healthcare system in the intermountain west, we performed a multicenter, retrospective cohort observational study. We compared 13,268 hospitalized patients with COVID pneumonia to 6673 patients with non -COVID-pneumonia. RESULTS Patients with COVID-19 were younger had fewer comorbidities, had lower mortality and greater length of hospital stay. Our regression models demonstrated that daily insulin dose, indexed for weight, was associated with COVID-19, age, diabetic status, HgbA1c, admission SOFA, ICU length of stay and receipt of corticosteroids. There was significant interaction between a diagnosis of diabetes and having COVID-19. Time in range for our IV insulin protocol was not correlated with having COVID after adjustment. It was correlated with ICU length of stay, diabetic control (HgbA1C) and prior history of diabetes. Among patients with subcutaneous (SQ) insulin only percent of glucose checks in range was correlated with diabetic status, having Covid-19, HgbA1c, total steroids given and Elixhauser comorbidity score even when controlled for other factors. CONCLUSIONS Hospitalized patients with COVID-19 pneumonia who receive insulin for glycemic control require both more SQ and IV insulin than the non-COVID-19 pneumonia counterparts. Patients with COVID-19 who received SQ insulin only had a lower percent of glucose checks in range.
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Affiliation(s)
- Daniel B Knox
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - James Orme
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Ithan Peltan
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michael J Lanspa
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
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Harris BR, Beesley SJ, Hopkins RO, Hirshberg EL, Wilson E, Butler J, Oniki TA, Kuttler KG, Orme JF, Brown SM. Heart rate variability and subsequent psychological distress among family members of intensive care unit patients. J Int Med Res 2021; 49:3000605211057829. [PMID: 34846178 PMCID: PMC8649465 DOI: 10.1177/03000605211057829] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective To determine whether heart rate variability (HRV; a physiological measure of
acute stress) is associated with persistent psychological distress among
family members of adult intensive care unit (ICU) patients. Methods This prospective study investigated family members of patients admitted to a
study ICU. Participants’ variability in heart rate tracings were measured by
low frequency (LF)/high frequency (HF) ratio and detrended fluctuation
analysis (DFA). Questionnaires were completed 3 months after enrollment to
ascertain outcome rates of anxiety, depression, and post-traumatic stress
disorder (PTSD). Results Ninety-nine participants were enrolled (median LF/HF ratio, 0.92
[interquartile range, 0.64–1.38]). Of 92 participants who completed the
3-month follow-up, 29 (32%) had persistent anxiety. Logistic regression
showed that LF/HF ratio (odds ratio [OR] 0.85, 95% confidence interval [CI]
0.43, 1.53) was not associated with 3-month outcomes. In an exploratory
analysis, DFA α (OR 0.93, 95% CI 0.87, 0.99), α1 (OR 0.97, 95% CI
0.94, 0.99), and α2 (OR 0.94, 95% CI 0.88, 0.99) scaling
components were associated with PTSD development. Conclusion Almost one-third of family members experienced anxiety at three months after
enrollment. HRV, measured by LF/HF ratio, was not a predictor of psychologic
distress, however, exploratory analyses indicated that DFA may be associated
with PTSD outcomes.
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Affiliation(s)
- Benjamin Re Harris
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sarah J Beesley
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Psychology Department and Neuroscience Center, 6756Brigham Young University, Brigham Young University, Provo, UT, USA
| | - Eliotte L Hirshberg
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Emily Wilson
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jorie Butler
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Geriatrics and Psychology, University of Utah and Salt Lake City Veterans Administration Hospital, Salt Lake City, UT, USA
| | - Thomas A Oniki
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Care Transformation Information Systems, 7061Intermountain Healthcare, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Kathryn G Kuttler
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Care Transformation Information Systems, 7061Intermountain Healthcare, Intermountain Healthcare, Salt Lake City, UT, USA
| | - James F Orme
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Samuel M Brown
- Center for Humanizing Critical Care, 7061Intermountain Healthcare, Intermountain Healthcare, Murray, UT, USA.,Pulmonary and Critical Care Medicine, 98078Intermountain Medical Center, 98078Intermountain Medical Center, Salt Lake City, UT, USA.,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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10
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Lanspa MJ, Cirulis MM, Wiley BM, Olsen TD, Wilson EL, Beesley SM, Brown SM, Hirshberg EL, Grissom CK. Response. Chest 2021; 160:e319-e320. [PMID: 34488980 PMCID: PMC8727847 DOI: 10.1016/j.chest.2021.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT.
| | - Meghan M Cirulis
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Troy D Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT
| | - Sarah M Beesley
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Eliotte L Hirshberg
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT; Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Colin K Grissom
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
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11
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Conlon TW, Kantor DB, Hirshberg EL, Fraga MV, Glau CL, Horowitz R, Burzynski JH, Godshall AJ, Nishisaki A. A Call to Action for the Pediatric Critical Care Community. Pediatr Crit Care Med 2021; 22:e410-e414. [PMID: 33653994 DOI: 10.1097/pcc.0000000000002691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Healthcare regulatory bodies have escalated concerns regarding the use of point-of-care ultrasound by nonradiology and noncardiology physicians. A recently published PCCMPerspective identified that data do not support many of these concerns and addressed common misconceptions associated with point-of-care ultrasound use in the critical care setting. Indeed, the global point-of-care ultrasound community and specifically the pediatric critical care community have the opportunity to be leaders in demonstrating how to translate new skills and technologies to the bedside in a safe and effective manner. We seek to extend the conversation and propose next steps in supporting integration of point-of-care ultrasound in pediatric critical care practice.
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Affiliation(s)
- Thomas W Conlon
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David B Kantor
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Eliotte L Hirshberg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Medicine, Division of Pulmonary and Critical Care, Intermountain Healthcare, Salt Lake City, UT
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Division of Emergency Medicine and Critical Care Medicine, Department of Pediatrics, Children's Hospital of Winnipeg, University of Manitoba, Winnipeg, MB, Canada
- Pediatric Critical Care Medicine, AdventHealth Medical Group, Orlando, FL
| | - Maria V Fraga
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Christie L Glau
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Russ Horowitz
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jeffrey H Burzynski
- Division of Emergency Medicine and Critical Care Medicine, Department of Pediatrics, Children's Hospital of Winnipeg, University of Manitoba, Winnipeg, MB, Canada
| | - Aaron J Godshall
- Pediatric Critical Care Medicine, AdventHealth Medical Group, Orlando, FL
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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12
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Hirshberg EL, Alexander JL, Asaro LA, Coughlin-Wells K, Steil GM, Spear D, Stone C, Nadkarni VM, Agus MSD. Performance of an Electronic Decision Support System as a Therapeutic Intervention During a Multicenter PICU Clinical Trial: Heart and Lung Failure-Pediatric Insulin Titration trial (HALF-PINT). Chest 2021; 160:919-928. [PMID: 33932465 PMCID: PMC8449010 DOI: 10.1016/j.chest.2021.04.049] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 11/21/2022] Open
Abstract
Background The use of electronic clinical decision support (CDS) systems for pediatric critical care trials is rare. We sought to describe in detail the use of a CDS tool (Children’s Hospital Euglycemia for Kids Spreadsheet [CHECKS]), for the management of hyperglycemia during the 32 multicenter Heart And Lung Failure-Pediatric Insulin Titration trial. Research Question In critically ill pediatric patients who were treated with CHECKS, how was user compliance associated with outcomes; and what patient and clinician factors might account for the observed differences in CHECKS compliance? Study Design and Methods During an observational retrospective study of compliance with a CDS tool used during a prospective randomized controlled trial, we compared patients with high and low CHECKS compliance. We investigated the association between compliance and blood glucose metrics. We describe CHECKS and use a computer interface analysis framework (the user, function, representation, and task analysis framework) to categorize user interactions. We discuss implications for future randomized controlled trials. Results Over a 4.5-year period, 658 of 698 children were treated with the CHECKS protocol for ≥24 hours with a median of 119 recommendations per patient. Compliance per patient was high (median, 99.5%), with only 30 patients having low compliance (<90%). Patients with low compliance were from 16 of 32 sites, younger (P = .02), and less likely to be on inotropic support (P = .04). They were more likely to be have been assigned randomly to the lower blood glucose target (80% vs 48%; P < .001) and to have spent a shorter time (53% vs 75%; P < .001) at the blood glucose target. Overrides (classified by the user, function, representation, and task analysis framework), were largely (89%) due to the user with patient factors contributing 29% of the time. Interpretation The use of CHECKS for the Heart And Lung Failure-Pediatric Insulin Titration trial resulted in a highly reproducible and explicit method for the management of hyperglycemia in critically ill children across varied environments. CDS systems represent an important mechanism for conducting explicit complex pediatric critical care trials. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT01565941, registered March 29 2012; https://clinicaltrials.gov/ct2/show/NCT01565941?term=HALF-PINT&draw=2&rank=1
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Affiliation(s)
- Eliotte L Hirshberg
- Pulmonary Division, Intermountain Medical Center, Salt Lake City, UT; Center for Humanizing Critical Care, Intermountain Healthcare, Salt Lake City, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT; Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, UT.
| | - Jamin L Alexander
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, MA
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kerry Coughlin-Wells
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, MA
| | - Garry M Steil
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, MA
| | - Debbie Spear
- Division of Pediatric Critical Care Medicine, Penn State Children's Hospital, Hershey, PA
| | - Cheryl Stone
- Pediatric Research Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michael S D Agus
- Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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13
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Lanspa MJ, Olsen TD, Wilson EL, Beesley SM, Brown SM, Hirshberg EL, Grissom CK, Cirulis MM, Wiley BM. Response. Chest 2021; 159:1685-1686. [PMID: 34022006 PMCID: PMC8500995 DOI: 10.1016/j.chest.2020.11.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/25/2020] [Indexed: 10/21/2022] Open
Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT.
| | - Troy D Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT
| | - Sarah M Beesley
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT; Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
| | - Meghan M Cirulis
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
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14
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Beesley SJ, Hirshberg EL, Wilson EL, Butler JM, Oniki TA, Kuttler KG, Orme JF, Hopkins RO, Brown SM. Depression and Change in Caregiver Burden Among Family Members of Intensive Care Unit Survivors. Am J Crit Care 2020; 29:350-357. [PMID: 32869070 DOI: 10.4037/ajcc2020181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Family members of patients in intensive care units may experience psychological distress and substantial caregiver burden. OBJECTIVE To evaluate whether change in caregiver burden from intensive care unit admission to 3-month follow-up is associated with caregiver depression at 3 months. METHODS Caregiver burden was assessed at enrollment and 3 months later, and caregiver depression was assessed at 3 months. Depression was measured with the Hospital Anxiety and Depression Score. The primary analysis was the association between depression at 3 months and change in caregiver burden, controlling for a history of caregiver depression. RESULTS One hundred one participants were enrolled; 65 participants had a surviving loved one and completed 3-month follow-up. At 3-month follow-up, 12% of participants met criteria for depression. Increased caregiver burden over time was significantly associated with depression at follow-up (Fisher exact test, P = .004), although this association was not significant after controlling for self-reported history of depression at baseline (Cochran-Mantel-Haenszel test, P = .23). CONCLUSIONS Family members are increasingly recognized as a vulnerable population susceptible to negative psychological outcomes after a loved one's admission to the intensive care unit. In this small sample, no significant association was found between change in caregiver burden and depression at 3 months after controlling for baseline depression.
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Affiliation(s)
- Sarah J. Beesley
- Sarah J. Beesley is an assistant professor, Pulmonary Division and Center for Humanizing Critical Care, Intermountain Medical Center and an adjunct assistant professor, Department of Medicine, University of Utah, both in Salt Lake City, Utah
| | - Eliotte L. Hirshberg
- Eliotte L. Hirshberg is an associate professor, Pulmonary Division and Center for Humanizing Critical Care, Intermountain Medical Center; an associate professor, Department of Internal Medicine, University of Utah School of Medicine; and an adjunct associate professor, Department of Pediatrics, University of Utah, all in Salt Lake City
| | - Emily L. Wilson
- Emily L. Wilson is a statistician, Pulmonary Division and Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City
| | - Jorie M. Butler
- Jorie M. Butler is an assistant professor, Department of Internal Medicine, Division of Geriatrics, University of Utah School of Medicine and an investigator with the Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Medical Center and the Center for Humanizing Critical Care, Intermountain Medical Center, all in Salt Lake City, Utah
| | - Thomas A. Oniki
- Thomas A. Oniki and Kathryn G. Kuttler are data specialists, Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, Utah
| | - Kathryn G. Kuttler
- Thomas A. Oniki and Kathryn G. Kuttler are data specialists, Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, Utah
| | - James F. Orme
- James F. Orme is a professor, Pulmonary Division and Center for Humanizing Critical Care, Intermountain Medical Center and a professor, Department of Medicine, University of Utah, both in Salt Lake City
| | - Ramona O. Hopkins
- Ramona O. Hopkins is a professor, Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah and the Pulmonary Division and Center for Humanizing Critical Care, Intermountain Medical Center, Salt Lake City, Utah
| | - Samuel M. Brown
- Samuel M. Brown is an associate professor, Pulmonary Division and Center for Humanizing Critical Care, Intermountain Medical Center and an associate professor, Department of Medicine, University of Utah, Salt Lake City
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15
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Remy KE, Verhoef PA, Malone JR, Ruppe MD, Kaselitz TB, Lodeserto F, Hirshberg EL, Slonim A, Dezfulian C. Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists. Pediatr Crit Care Med 2020; 21:607-619. [PMID: 32420720 PMCID: PMC7331597 DOI: 10.1097/pcc.0000000000002429] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE In the midst of the severe acute respiratory syndrome coronavirus 2 pandemic, which causes coronavirus disease 2019, there is a recognized need to expand critical care services and beds beyond the traditional boundaries. There is considerable concern that widespread infection will result in a surge of critically ill patients that will overwhelm our present adult ICU capacity. In this setting, one proposal to add "surge capacity" has been the use of PICU beds and physicians to care for these critically ill adults. DESIGN Narrative review/perspective. SETTING Not applicable. PATIENTS Not applicable. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The virus's high infectivity and prolonged asymptomatic shedding have resulted in an exponential growth in the number of cases in the United States within the past weeks with many (up to 6%) developing acute respiratory distress syndrome mandating critical care services. Coronavirus disease 2019 critical illness appears to be primarily occurring in adults. Although pediatric intensivists are well versed in the care of acute respiratory distress syndrome from viral pneumonia, the care of differing aged adult populations presents some unique challenges. In this statement, a team of adult and pediatric-trained critical care physicians provides guidance on common "adult" issues that may be encountered in the care of these patients and how they can best be managed in a PICU. CONCLUSIONS This concise scientific statement includes references to the most recent and relevant guidelines and clinical trials that shape management decisions. The intention is to assist PICUs and intensivists in rapidly preparing for care of adult coronavirus disease 2019 patients should the need arise.
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Affiliation(s)
- Kenneth E Remy
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO
| | - Philip A Verhoef
- Department of Internal Medicine, University of Hawaii-Manoa, Manoa, HI
- Kaiser Permanente Hawaii, Honolulu, HI
| | - Jay R Malone
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Michael D Ruppe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Norton Healthcare, University of Louisville, Louisville, KY
| | - Timothy B Kaselitz
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Frank Lodeserto
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Danville, PA
- Department of Pediatrics, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care, Department of Internal Medicine and Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Anthony Slonim
- University of Nevada, Reno School of Medicine, Renown Health System, Reno, NV
| | - Cameron Dezfulian
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA
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16
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Hirshberg EL, Butler J, Francis M, Davis FA, Lee D, Tavake-Pasi F, Napia E, Villalta J, Mukundente V, Coulter H, Stark L, Beesley SJ, Orme JF, Brown SM, Hopkins RO. Persistence of patient and family experiences of critical illness. BMJ Open 2020; 10:e035213. [PMID: 32265244 PMCID: PMC7245383 DOI: 10.1136/bmjopen-2019-035213] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate: (1) patient and family experiences with healthcare and the intensive care unit (ICU); (2) experiences during their critical illness; (3) communication and decision making during critical illness; (4) feelings about the ICU experience; (5) impact of the critical illness on their lives; and (6) concerns about their future after the ICU. DESIGN Four semistructured focus group interviews with former ICU patients and family members. SETTINGS Multicultural community group and local hospitals containing medical/surgical ICUs. PARTICIPANTS Patients and family who experienced a critical illness within the previous 10 years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four separate focus groups each lasting a maximum of 150 min and consisting of a total of 21 participants were held. Focus groups were conducted using a semistructured script including six topics relating to the experience of critical illness that facilitated deduction and the sorting of data by thematic analysis into five predominant themes. The five main themes that emerged from the data were: (1) personalised stories of the critical illness; (2) communication and shared decision making, (3) adjustment to life after critical illness, (4) trust towards clinical team and relevance of cultural beliefs and (5) end-of-life decision making. Across themes, we observed a misalignment between the medical system and patient and family values and priorities. CONCLUSIONS The experience of critical illness of a diverse group of patients and families can remain vivid for years after ICU discharge. The identified themes reflect the strength of memory of such pivotal experiences and the importance of a narrative around those experiences. Clinicians need to be aware of the lasting effects of critical illness has on patients and families.
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Affiliation(s)
- Eliotte L Hirshberg
- Center for Humanizing Critical Care, Internountain Medical Center, Murray, Utah, USA
- Department of Medicine, Division of Pulmonary and Critical Care, Intermountain Healthcare, Murray, Utah, USA
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Pediatrics, University of Utah, School of Medicine, Salt Lake City, Utah, USA
| | - Jorie Butler
- Center for Humanizing Critical Care, Internountain Medical Center, Murray, Utah, USA
- Department of Geriatrics, Univeristy of Utah, Salt Lake City, Utah, USA
- Geriatrics Research Education and Clinical Center, Veterans Affairs Medical Center (VAMC, Salt Lake City, Utah, USA
| | - Morgan Francis
- Department of Medicine, Division of Pulmonary and Critical Care, Intermountain Healthcare, Murray, Utah, USA
| | | | - Doriena Lee
- Community Faces of Utah, Salt Lake City, Utah, USA
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | | | - Edwin Napia
- Community Faces of Utah, Salt Lake City, Utah, USA
| | | | | | - Heather Coulter
- Community Faces of Utah, Salt Lake City, Utah, USA
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Louisa Stark
- Community Faces of Utah, Salt Lake City, Utah, USA
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Sarah J Beesley
- Center for Humanizing Critical Care, Internountain Medical Center, Murray, Utah, USA
- Department of Medicine, Division of Pulmonary and Critical Care, Intermountain Healthcare, Murray, Utah, USA
| | - James F Orme
- Center for Humanizing Critical Care, Internountain Medical Center, Murray, Utah, USA
- Department of Medicine, Division of Pulmonary and Critical Care, Intermountain Healthcare, Murray, Utah, USA
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Samuel M Brown
- Center for Humanizing Critical Care, Internountain Medical Center, Murray, Utah, USA
- Department of Medicine, Division of Pulmonary and Critical Care, Intermountain Healthcare, Murray, Utah, USA
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Internountain Medical Center, Murray, Utah, USA
- Department of Medicine, Division of Pulmonary and Critical Care, Intermountain Healthcare, Murray, Utah, USA
- Department of Psychology and Neuroscience, Brigham Young University, Provo, Utah, USA
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17
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Cirulis MM, Beesley SJ, Wilson EL, Stubben C, Olsen TD, Hirshberg EL, Smith LM, Lanspa MJ, Abraham TP, Grissom CK, Rondina MT, Brown SM. The peripheral blood transcriptome in septic cardiomyopathy: an observational, pilot study. Intensive Care Med Exp 2019; 7:57. [PMID: 31650252 PMCID: PMC6813402 DOI: 10.1186/s40635-019-0271-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/24/2019] [Indexed: 01/25/2023] Open
Abstract
Background Septic cardiomyopathy (SCM) is common in sepsis and associated with increased morbidity and mortality. Left ventricular global longitudinal strain (LV GLS), measured by speckle tracking echocardiography, allows improved identification of impaired cardiac contractility. The peripheral blood transcriptome may be an important window into SCM pathophysiology. We therefore studied the peripheral blood transcriptome and LV GLS in a prospective cohort of patients with sepsis. Results In this single-center observational pilot study, we enrolled adult patients (age > 18) with sepsis within 48 h of admission to the ICU. SCM was defined as LV GLS > − 17% based on echocardiograms performed within 72 h of admission. We enrolled 27 patients, 24 of whom had high-quality RNA results; 18 (75%) of 24 had SCM. The group was 50% female and had a median (IQR) age of 59.5 (48.5–67.0) years and admission APACHE II score of 21.0 (16.0–32.3). Forty-six percent had septic shock. After filtering for low-expression and non-coding genes, 15,418 protein coding genes were expressed and 73 had significantly different expression between patients with vs. without SCM. In patients with SCM, 43 genes were upregulated and 30 were downregulated. Pathway analysis identified enrichment in type 1 interferon signaling (adjusted p < 10−5). Conclusions In this hypothesis-generating study, SCM was associated with upregulation of genes in the type 1 interferon signaling pathway. Interferons are cytokines that stimulate the innate and adaptive immune response and are implicated in the early proinflammatory and delayed immunosuppression phases of sepsis. While type 1 interferons have not been implicated previously in SCM, interferon therapy (for viral hepatitis and Kaposi sarcoma) has been associated with reversible cardiomyopathy, perhaps suggesting a role for interferon signaling in SCM.
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Affiliation(s)
- Meghan M Cirulis
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA. .,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.
| | - Sarah J Beesley
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA.,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Emily L Wilson
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Chris Stubben
- Bioinformatics Shared Resource, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Troy D Olsen
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA
| | - Eliotte L Hirshberg
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA.,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Lane M Smith
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Michael J Lanspa
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA.,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Theodore P Abraham
- Division of Cardiology, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Colin K Grissom
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
| | - Matthew T Rondina
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, USA.,Molecular Medicine Program, University of Utah, Salt Lake City, UT, USA
| | - Samuel M Brown
- Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Medicine, University of Utah, Salt Lake City, UT, USA.,Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Shock Trauma Intensive Care Unit, 5121 South Cottonwood Street, Murray, UT, 84107 42, USA.,Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
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18
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Lanspa MJ, Olsen TD, Wilson EL, Leguyader ML, Hirshberg EL, Anderson JL, Brown SM, Grissom CK. A simplified definition of diastolic function in sepsis, compared against standard definitions. J Intensive Care 2019; 7:14. [PMID: 30820322 PMCID: PMC6381727 DOI: 10.1186/s40560-019-0367-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/24/2019] [Indexed: 01/20/2023] Open
Abstract
Background Guidelines for grading diastolic dysfunction poorly categorize septic patients. We compared how well the American Society of Echocardiography (ASE) 2009 and 2016 definitions and a simplified definition categorized septic patients. Methods We studied septic patients who received a transthoracic echocardiogram within 24 h of admission to an ICU. We categorized patients according to ASE 2009 and 2016 definitions and a definition using E/e’, a surrogate for left ventricular filling pressure. We assessed 28-day all-cause mortality and the presence of pre-existing diabetes, hypertension, or myocardial infarction. We tested for associations among diastolic grade, comorbidities, and outcomes using logistic regression. Results We studied 398 patients. Mortality was 23%. The simplified definition categorized more patients than ASE 2016 (78% vs. 71%, p = 0.035); both definitions categorized more patients than ASE 2009 (34%, p < 0.001 for both comparisons). Higher grades of diastolic dysfunction were associated with hypertension (ASE 2016, simplified), myocardial infarction (ASE 2009, simplified), and diabetes (simplified). Grade of diastolic dysfunction was not associated with mortality by any definition. Of 199 patients categorized as normal by ASE 2016, 40% had an abnormal E/e′ > 9 and 7% had a severely abnormal E/e′ > 13. Conclusions The ASE 2016 definition categorizes more septic patients than the ASE 2009 definition, but it does not categorize the diastolic function of a third of septic patients. ASE 2016 designates many patients with elevated E/e′ as normal. A simplified definition categorized patients with less ambiguity and is associated with relevant comorbidities. Electronic supplementary material The online version of this article (10.1186/s40560-019-0367-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael J Lanspa
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA
| | - Troy D Olsen
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA
| | - Emily L Wilson
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA
| | - Mary Louise Leguyader
- 3Department of Internal Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT 84132 USA
| | - Eliotte L Hirshberg
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA.,4Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108 USA
| | - Jeffrey L Anderson
- 5Intermountain Medical Center Heart Institute, 5121 S Cottonwood St, Murray, UT 84157 USA.,6Division of Cardiology, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA
| | - Samuel M Brown
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA
| | - Colin K Grissom
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT 84157 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT 84132 USA
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19
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McPeake J, Hirshberg EL, Christie LM, Drumright K, Haines K, Hough CL, Meyer J, Wade D, Andrews A, Bakhru R, Bates S, Barwise JA, Bastarache J, Beesley SJ, Boehm LM, Brown S, Clay AS, Firshman P, Greenberg S, Harris W, Hill C, Hodgson C, Holdsworth C, Hope AA, Hopkins RO, Howell DCJ, Janssen A, Jackson JC, Johnson A, Kross EK, Lamas D, MacLeod-Smith B, Mandel R, Marshall J, Mikkelsen ME, Nackino M, Quasim T, Sevin CM, Slack A, Spurr R, Still M, Thompson C, Weinhouse G, Wilcox ME, Iwashyna TJ. Models of Peer Support to Remediate Post-Intensive Care Syndrome: A Report Developed by the Society of Critical Care Medicine Thrive International Peer Support Collaborative. Crit Care Med 2019; 47:e21-e27. [PMID: 30422863 PMCID: PMC6719778 DOI: 10.1097/ccm.0000000000003497] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [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: 11/26/2022]
Abstract
OBJECTIVES Patients and caregivers can experience a range of physical, psychologic, and cognitive problems following critical care discharge. The use of peer support has been proposed as an innovative support mechanism. DESIGN We sought to identify technical, safety, and procedural aspects of existing operational models of peer support, among the Society of Critical Care Medicine Thrive Peer Support Collaborative. We also sought to categorize key distinctions between these models and elucidate barriers and facilitators to implementation. SUBJECTS AND SETTING Seventeen Thrive sites from the United States, United Kingdom, and Australia were represented by a range of healthcare professionals. MEASUREMENTS AND MAIN RESULTS Via an iterative process of in-person and email/conference calls, members of the Collaborative defined the key areas on which peer support models could be defined and compared, collected detailed self-reports from all sites, reviewed the information, and identified clusters of models. Barriers and challenges to implementation of peer support models were also documented. Within the Thrive Collaborative, six general models of peer support were identified: community based, psychologist-led outpatient, models-based within ICU follow-up clinics, online, groups based within ICU, and peer mentor models. The most common barriers to implementation were recruitment to groups, personnel input and training, sustainability and funding, risk management, and measuring success. CONCLUSIONS A number of different models of peer support are currently being developed to help patients and families recover and grow in the postcritical care setting.
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Affiliation(s)
- Joanne McPeake
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- University of Glasgow, Glasgow, United Kingdom
| | - Eliotte L Hirshberg
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Leeann M Christie
- Dell Children's Medical Centre, Austin, TX
- VA Tennessee Valley Healthcare System, Nashville, TN
| | | | - Kimberley Haines
- Western Health, Melbourne, VIC, Australia
- Australia and New Zealand Intensive Care Society Research Centre, Monash University, Melbourne, VIC, Australia
| | - Catherine L Hough
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Joel Meyer
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dorothy Wade
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Rita Bakhru
- Pulmonary, Critical Care, Allergy & Immunologic Diseases, Wake Forest School of Medicine, Winston Salem, NC
| | | | - John A Barwise
- VA Tennessee Valley Healthcare System, Nashville, TN
- Vanderbilt University Medical Center, Nashville, TN
| | - Julie Bastarache
- VA Tennessee Valley Healthcare System, Nashville, TN
- Vanderbilt University Medical Center, Nashville, TN
| | - Sarah J Beesley
- Intermountain Medical Center, Division of Pulmonary and Critical Care, Murray, UT
- Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT
| | - Leanne M Boehm
- Vanderbilt University School of Nursing, Nashville, TN
- VA Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, TN
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | | | | | - Penelope Firshman
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Steven Greenberg
- Evanston Hospital, NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, Chicago, IL
| | - Wendy Harris
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Carol Hodgson
- Australia and New Zealand Intensive Care Society Research Centre, Monash University, Melbourne, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
| | | | | | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT
- Intermountain Medical Center, Division of Pulmonary and Critical Care, Murray, UT
- Department of Psychology and Neuroscience Center, Brigham Young University, Provo, UT
| | - David C J Howell
- Critical Care Unit, University College London NHS Foundation Trust, London, United Kingdom
| | - Anna Janssen
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | - Erin K Kross
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
| | - Daniela Lamas
- Division of Pulmonary and Critical Care Medicine, Brigham & Women's Hospital, Boston, MA
| | | | - Ruth Mandel
- NorthShore University Health System - Evanston Hospital, Chicago, IL
| | | | - Mark E Mikkelsen
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine of the University of Pennsylvania, Pennsylvania, PA
| | - Megan Nackino
- University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Tara Quasim
- NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- University of Glasgow, Glasgow, United Kingdom
| | - Carla M Sevin
- Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew Slack
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Rachel Spurr
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Mary Still
- Emory University Hospital (Emory Healthcare), Atlanta, GA
| | - Carol Thompson
- College of Nursing, University of Kentucky, Lexington, KY
| | - Gerald Weinhouse
- Division of Pulmonary and Critical Care Medicine, Brigham & Women's Hospital, Boston, MA
| | - M Elizabeth Wilcox
- Division of Respirology, Department of Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - Theodore J Iwashyna
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI
- Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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20
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Lanspa MJ, Burk RE, Wilson EL, Hirshberg EL, Grissom CK, Brown SM. Echocardiogram-guided resuscitation versus early goal-directed therapy in the treatment of septic shock: a randomized, controlled, feasibility trial. J Intensive Care 2018; 6:50. [PMID: 30123511 PMCID: PMC6090604 DOI: 10.1186/s40560-018-0319-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 06/07/2018] [Accepted: 08/02/2018] [Indexed: 12/20/2022] Open
Abstract
Objective Echocardiography is often used to guide septic shock resuscitation, but without evidence for efficacy. We conducted an intensive care unit (ICU)-based randomized controlled feasibility trial comparing echocardiography-guided septic shock resuscitation (ECHO) with early goal-directed therapy (EGDT). Methods We conducted a single center, randomized controlled feasibility trial at a 468-bed academic tertiary care center in Utah, USA. Adult patients with early septic shock were assessed and treated at defined intervals over 6 h using an echocardiogram-guided resuscitation protocol or a slightly modified EGDT protocol. Feasibility outcomes were fluid balance, dobutamine administration, and time to lactate clearance. The primary clinical outcome was changed in sequential organ failure assessment score at 48 h (delta SOFA). Secondary outcomes included inpatient mortality, ICU-free days, and ventilator-free days at 28 days. Results Thirty participants, 15 per group, were randomized and completed the study. Baseline characteristics were similar between groups. Patients were randomized within a median of 3.5 h of meeting inclusion criteria but had received a median of 3 L crystalloid by then. Fluid administration during the study protocol was similar in both groups (median ECHO 0 vs EGDT 1 L, p = 0.61). Eleven (73%) subjects in each arm received ≤ 1 L fluid. Dobutamine administration was also similar (20% vs 13%, p > 0.99). Twenty-one patients (70%) had lactate clearance prior to the first study assessment. No difference was observed in delta SOFA (median − 4 for ECHO vs − 6 for EGDT, p = 0.10) nor mortality (33% ECHO vs 20% EGDT, p = 0.68). Conclusions No experimental separation was observed in this randomized, controlled feasibility trial. Early lactate clearance, coupled with substantial fluid administration before randomization, suggests that patients were already resuscitated before arrival in the ICU. Future trials of echocardiogram-guided sepsis resuscitation will likely need to enroll in the emergency department. Trial registration This study was retrospectively registered at clinicaltrials.gov (identifier NCT02354742, title Echo vs EGDT in severe sepsis and septic shock) on February 3, 2015. Registration was completed before review or analysis of any data. Electronic supplementary material The online version of this article (10.1186/s40560-018-0319-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael J Lanspa
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84107 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132 USA
| | - Rebecca E Burk
- 2Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132 USA
| | - Emily L Wilson
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84107 USA
| | - Eliotte L Hirshberg
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84107 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132 USA.,3Division of Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT 84132 USA
| | - Colin K Grissom
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84107 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132 USA
| | - Samuel M Brown
- 1Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT 84107 USA.,2Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132 USA
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Kantor DB, Hirshberg EL, McDonald MC, Griffin J, Buccigrosso T, Stenquist N, Smallwood CD, Nelson KA, Zurakowski D, Phipatanakul W, Hirschhorn JN. Fluid Balance Is Associated with Clinical Outcomes and Extravascular Lung Water in Children with Acute Asthma Exacerbation. Am J Respir Crit Care Med 2018; 197:1128-1135. [PMID: 29313715 PMCID: PMC6019929 DOI: 10.1164/rccm.201709-1860oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 09/13/2017] [Accepted: 01/08/2018] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The effects of fluid administration during acute asthma exacerbation are likely unique in this patient population: highly negative inspiratory intrapleural pressure resulting from increased airway resistance may interact with excess fluid administration to favor the accumulation of extravascular lung water, leading to worse clinical outcomes. OBJECTIVES Investigate how fluid balance influences clinical outcomes in children hospitalized for asthma exacerbation. METHODS We analyzed the association between fluid overload and clinical outcomes in a retrospective cohort of children admitted to an urban children's hospital with acute asthma exacerbation. These findings were validated in two cohorts: a matched retrospective and a prospective observational cohort. Finally, ultrasound imaging was used to identify extravascular lung water and investigate the physiological basis for the inferential findings. MEASUREMENTS AND MAIN RESULTS In the retrospective cohort, peak fluid overload [(fluid input - output)/weight] is associated with longer hospital length of stay, longer treatment duration, and increased risk of supplemental oxygen use (P values < 0.001). Similar results were obtained in the validation cohorts. There was a strong interaction between fluid balance and intrapleural pressure: the combination of positive fluid balance and highly negative inspiratory intrapleural pressures is associated with signs of increased extravascular lung water (P < 0.001), longer length of stay (P = 0.01), longer treatment duration (P = 0.03), and increased risk of supplemental oxygen use (P = 0.02). CONCLUSIONS Excess volume administration leading to fluid overload in children with acute asthma exacerbation is associated with increased extravascular lung water and worse clinical outcomes.
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Affiliation(s)
- David B. Kantor
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine
- Department of Anaesthesia
| | - Eliotte L. Hirshberg
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Intermountain Medical Center, Murray, Utah
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah; and
| | | | - John Griffin
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine
| | | | - Nicole Stenquist
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine
| | - Craig D. Smallwood
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine
- Department of Anaesthesia
| | - Kyle A. Nelson
- Division of Pediatric Emergency Medicine
- Department of Pediatrics, and
| | - David Zurakowski
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine
- Department of Anaesthesia
| | | | - Joel N. Hirschhorn
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Genetics, Harvard Medical School, Boston, Massachusetts
- Program in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts
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22
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Hersh AM, Hirshberg EL, Wilson EL, Orme JF, Morris AH, Lanspa MJ. Lower Glucose Target Is Associated With Improved 30-Day Mortality in Cardiac and Cardiothoracic Patients. Chest 2018; 154:1044-1051. [PMID: 29705217 DOI: 10.1016/j.chest.2018.04.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/12/2018] [Accepted: 04/16/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Practice guidelines recommend against intensive insulin therapy in patients who are critically ill based on trials that had high rates of severe hypoglycemia. Intermountain Healthcare uses a computerized IV insulin protocol that allows choice of blood glucose (BG) targets (80-110 vs 90-140 mg/dL) and has low rates of severe hypoglycemia. We sought to study the effects of BG target on mortality in adult patients in cardiac ICUs that have very low rates of severe hypoglycemia. METHODS Critically ill patients receiving IV insulin were treated with either of two BG targets (80-110 vs 90-140 mg/dL). We created a propensity score for BG target using factors thought to have influenced clinicians' choice, and then we performed a propensity score-adjusted regression analysis for 30-day mortality. RESULTS There were 1,809 patients who met inclusion criteria. Baseline patient characteristics were similar. Median glucose was lower in the 80-110 mg/dL group (104 vs 122 mg/dL, P < .001). Severe hypoglycemia occurred at very low rates in both groups (1.16% vs 0.35%, P = .051). Unadjusted 30-day mortality was lower in the 80-110 mg/dL group (4.3% vs 9.2%, P < .001). This remained after propensity score-adjusted regression (OR, 0.65; 95% CI, 0.43-0.98; P = .04). CONCLUSIONS Tight glucose control can be achieved with low rates of severe hypoglycemia and is associated with decreased 30-day mortality in a cohort of largely patients in cardiac ICUs. Although such findings should not be used to guide clinical practice at present, the use of tight glucose control should be reexamined using a protocol that has low rates of severe hypoglycemia.
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Affiliation(s)
- Andrew M Hersh
- Division of Pulmonary and Critical Care, San Antonio Military Medical Center, Fort Sam Houston, TX; Division of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT.
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT; Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Emily L Wilson
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT
| | - James F Orme
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Alan H Morris
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Michael J Lanspa
- Division of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT
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23
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Lah S, Wilson EL, Rozenblum R, Hirshberg EL, Hopkins RO, Orme J, Brown SM. Patient and Family Experience: A Comparison of Intensive Care and Overall Hospitalization. Am J Crit Care 2017; 26:194-202. [PMID: 28461541 DOI: 10.4037/ajcc2017143] [Citation(s) in RCA: 2] [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: 11/01/2022]
Abstract
BACKGROUND The Hospital Consumer Assessment of Healthcare Providers and Systems survey is the most commonly used instrument for measuring patients' perceptions of the quality of inpatient care. OBJECTIVE To determine if the hospital survey can also be used to measure patients' experience of intensive care as indicated by scores on a parallel questionnaire, the Patient Perception of Quality. METHODS Scores on both instruments of all adult patients admitted to an intensive care unit from 2007 through 2012 were analyzed. RESULTS A total of 1766 matching pairs of hospital and critical care surveys were identified. Patients' ratings of the overall hospital and critical care experiences had low correlation: r = 0.32 (95% CI, 0.28-0.37). Using the standard reporting convention, 77% of the participants rated the hospital as 9 or 10 on a 10-point scale, and 65% rated the intensive care unit as 5 on a 5-point scale. Although the hospital survey was always completed by the patient, the critical care survey was completed by a patient's family member or friend in 76% of cases and by the patient in 24%. Patient-completed critical care surveys had more correlation with hospital surveys (r = 0.45) than did critical care surveys completed by family members (r = 0.30), but the overall correlation remained modest. CONCLUSION Scores on the hospital survey were at best modestly associated with scores on the critical care survey and did not reflect the specific experiences of patients and patients' families in the intensive care unit.
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Affiliation(s)
- Soowhan Lah
- Soowhan Lah was a fellow in pulmonary and critical care medicine, University of Utah School of Medicine, Salt Lake City, Utah, and is an assistant professor of medicine, Metropolitan Hospital, New York Medical College, New York, New York. Emily L. Wilson is a statistician, Center for Humanizing Critical Care and the Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Murray, Utah. Ronen Rozenblum is founding director, Unit for Innovative Healthcare Practice and Technology, director of business development, Center for Patient Safety Research and Practice, Brigham and Women's Hospital; and an assistant professor, Harvard Medical School, Boston, Massachusetts. Eliotte L. Hirshberg is associate director, Center for Humanizing Critical Care, Intermountain Healthcare; an associate professor, Department of Pulmonary and Critical Care Medicine, University of Utah; and an intensivist in both the Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, and the Department of Pediatrics, Division of Critical Care, Primary Children's Hospital and the University of Utah. Ramona O. Hopkins is a research psychologist, Center for Humanizing Critical Care, a researcher, Pulmonary and Critical Care Medicine, Intermountain Medical Center, and a professor, Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah. James Orme is director, shock-trauma intensive care unit, Pulmonary and Critical Care Division, Intermountain Medical Center, and professor of medicine, University of Utah. Samuel M. Brown is director, Center for Humanizing Critical Care, Intermountain Healthcare; an intensivist, Pulmonary and Critical Care Medicine, Intermountain Medical Center; and an associate professor, Pulmonary and Critical Care Medicine, University of Utah
| | - Emily L Wilson
- Soowhan Lah was a fellow in pulmonary and critical care medicine, University of Utah School of Medicine, Salt Lake City, Utah, and is an assistant professor of medicine, Metropolitan Hospital, New York Medical College, New York, New York. Emily L. Wilson is a statistician, Center for Humanizing Critical Care and the Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Murray, Utah. Ronen Rozenblum is founding director, Unit for Innovative Healthcare Practice and Technology, director of business development, Center for Patient Safety Research and Practice, Brigham and Women's Hospital; and an assistant professor, Harvard Medical School, Boston, Massachusetts. Eliotte L. Hirshberg is associate director, Center for Humanizing Critical Care, Intermountain Healthcare; an associate professor, Department of Pulmonary and Critical Care Medicine, University of Utah; and an intensivist in both the Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, and the Department of Pediatrics, Division of Critical Care, Primary Children's Hospital and the University of Utah. Ramona O. Hopkins is a research psychologist, Center for Humanizing Critical Care, a researcher, Pulmonary and Critical Care Medicine, Intermountain Medical Center, and a professor, Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah. James Orme is director, shock-trauma intensive care unit, Pulmonary and Critical Care Division, Intermountain Medical Center, and professor of medicine, University of Utah. Samuel M. Brown is director, Center for Humanizing Critical Care, Intermountain Healthcare; an intensivist, Pulmonary and Critical Care Medicine, Intermountain Medical Center; and an associate professor, Pulmonary and Critical Care Medicine, University of Utah
| | - Ronen Rozenblum
- Soowhan Lah was a fellow in pulmonary and critical care medicine, University of Utah School of Medicine, Salt Lake City, Utah, and is an assistant professor of medicine, Metropolitan Hospital, New York Medical College, New York, New York. Emily L. Wilson is a statistician, Center for Humanizing Critical Care and the Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Murray, Utah. Ronen Rozenblum is founding director, Unit for Innovative Healthcare Practice and Technology, director of business development, Center for Patient Safety Research and Practice, Brigham and Women's Hospital; and an assistant professor, Harvard Medical School, Boston, Massachusetts. Eliotte L. Hirshberg is associate director, Center for Humanizing Critical Care, Intermountain Healthcare; an associate professor, Department of Pulmonary and Critical Care Medicine, University of Utah; and an intensivist in both the Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, and the Department of Pediatrics, Division of Critical Care, Primary Children's Hospital and the University of Utah. Ramona O. Hopkins is a research psychologist, Center for Humanizing Critical Care, a researcher, Pulmonary and Critical Care Medicine, Intermountain Medical Center, and a professor, Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah. James Orme is director, shock-trauma intensive care unit, Pulmonary and Critical Care Division, Intermountain Medical Center, and professor of medicine, University of Utah. Samuel M. Brown is director, Center for Humanizing Critical Care, Intermountain Healthcare; an intensivist, Pulmonary and Critical Care Medicine, Intermountain Medical Center; and an associate professor, Pulmonary and Critical Care Medicine, University of Utah
| | - Eliotte L Hirshberg
- Soowhan Lah was a fellow in pulmonary and critical care medicine, University of Utah School of Medicine, Salt Lake City, Utah, and is an assistant professor of medicine, Metropolitan Hospital, New York Medical College, New York, New York. Emily L. Wilson is a statistician, Center for Humanizing Critical Care and the Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Murray, Utah. Ronen Rozenblum is founding director, Unit for Innovative Healthcare Practice and Technology, director of business development, Center for Patient Safety Research and Practice, Brigham and Women's Hospital; and an assistant professor, Harvard Medical School, Boston, Massachusetts. Eliotte L. Hirshberg is associate director, Center for Humanizing Critical Care, Intermountain Healthcare; an associate professor, Department of Pulmonary and Critical Care Medicine, University of Utah; and an intensivist in both the Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, and the Department of Pediatrics, Division of Critical Care, Primary Children's Hospital and the University of Utah. Ramona O. Hopkins is a research psychologist, Center for Humanizing Critical Care, a researcher, Pulmonary and Critical Care Medicine, Intermountain Medical Center, and a professor, Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah. James Orme is director, shock-trauma intensive care unit, Pulmonary and Critical Care Division, Intermountain Medical Center, and professor of medicine, University of Utah. Samuel M. Brown is director, Center for Humanizing Critical Care, Intermountain Healthcare; an intensivist, Pulmonary and Critical Care Medicine, Intermountain Medical Center; and an associate professor, Pulmonary and Critical Care Medicine, University of Utah
| | - Ramona O Hopkins
- Soowhan Lah was a fellow in pulmonary and critical care medicine, University of Utah School of Medicine, Salt Lake City, Utah, and is an assistant professor of medicine, Metropolitan Hospital, New York Medical College, New York, New York. Emily L. Wilson is a statistician, Center for Humanizing Critical Care and the Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Murray, Utah. Ronen Rozenblum is founding director, Unit for Innovative Healthcare Practice and Technology, director of business development, Center for Patient Safety Research and Practice, Brigham and Women's Hospital; and an assistant professor, Harvard Medical School, Boston, Massachusetts. Eliotte L. Hirshberg is associate director, Center for Humanizing Critical Care, Intermountain Healthcare; an associate professor, Department of Pulmonary and Critical Care Medicine, University of Utah; and an intensivist in both the Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, and the Department of Pediatrics, Division of Critical Care, Primary Children's Hospital and the University of Utah. Ramona O. Hopkins is a research psychologist, Center for Humanizing Critical Care, a researcher, Pulmonary and Critical Care Medicine, Intermountain Medical Center, and a professor, Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah. James Orme is director, shock-trauma intensive care unit, Pulmonary and Critical Care Division, Intermountain Medical Center, and professor of medicine, University of Utah. Samuel M. Brown is director, Center for Humanizing Critical Care, Intermountain Healthcare; an intensivist, Pulmonary and Critical Care Medicine, Intermountain Medical Center; and an associate professor, Pulmonary and Critical Care Medicine, University of Utah
| | - James Orme
- Soowhan Lah was a fellow in pulmonary and critical care medicine, University of Utah School of Medicine, Salt Lake City, Utah, and is an assistant professor of medicine, Metropolitan Hospital, New York Medical College, New York, New York. Emily L. Wilson is a statistician, Center for Humanizing Critical Care and the Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Murray, Utah. Ronen Rozenblum is founding director, Unit for Innovative Healthcare Practice and Technology, director of business development, Center for Patient Safety Research and Practice, Brigham and Women's Hospital; and an assistant professor, Harvard Medical School, Boston, Massachusetts. Eliotte L. Hirshberg is associate director, Center for Humanizing Critical Care, Intermountain Healthcare; an associate professor, Department of Pulmonary and Critical Care Medicine, University of Utah; and an intensivist in both the Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, and the Department of Pediatrics, Division of Critical Care, Primary Children's Hospital and the University of Utah. Ramona O. Hopkins is a research psychologist, Center for Humanizing Critical Care, a researcher, Pulmonary and Critical Care Medicine, Intermountain Medical Center, and a professor, Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah. James Orme is director, shock-trauma intensive care unit, Pulmonary and Critical Care Division, Intermountain Medical Center, and professor of medicine, University of Utah. Samuel M. Brown is director, Center for Humanizing Critical Care, Intermountain Healthcare; an intensivist, Pulmonary and Critical Care Medicine, Intermountain Medical Center; and an associate professor, Pulmonary and Critical Care Medicine, University of Utah
| | - Samuel M Brown
- Soowhan Lah was a fellow in pulmonary and critical care medicine, University of Utah School of Medicine, Salt Lake City, Utah, and is an assistant professor of medicine, Metropolitan Hospital, New York Medical College, New York, New York. Emily L. Wilson is a statistician, Center for Humanizing Critical Care and the Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Murray, Utah. Ronen Rozenblum is founding director, Unit for Innovative Healthcare Practice and Technology, director of business development, Center for Patient Safety Research and Practice, Brigham and Women's Hospital; and an assistant professor, Harvard Medical School, Boston, Massachusetts. Eliotte L. Hirshberg is associate director, Center for Humanizing Critical Care, Intermountain Healthcare; an associate professor, Department of Pulmonary and Critical Care Medicine, University of Utah; and an intensivist in both the Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, and the Department of Pediatrics, Division of Critical Care, Primary Children's Hospital and the University of Utah. Ramona O. Hopkins is a research psychologist, Center for Humanizing Critical Care, a researcher, Pulmonary and Critical Care Medicine, Intermountain Medical Center, and a professor, Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah. James Orme is director, shock-trauma intensive care unit, Pulmonary and Critical Care Division, Intermountain Medical Center, and professor of medicine, University of Utah. Samuel M. Brown is director, Center for Humanizing Critical Care, Intermountain Healthcare; an intensivist, Pulmonary and Critical Care Medicine, Intermountain Medical Center; and an associate professor, Pulmonary and Critical Care Medicine, University of Utah.
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Hirshberg EL, Lanspa MJ, Wilson EL, Sward KA, Jephson A, Larsen GY, Morris AH. A Pediatric Intensive Care Unit Bedside Computer Clinical Decision Support Protocol for Hyperglycemia Is Feasible, Safe and Offers Advantages. Diabetes Technol Ther 2017; 19:188-193. [PMID: 28248127 PMCID: PMC5359657 DOI: 10.1089/dia.2016.0423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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] [Indexed: 02/02/2023]
Abstract
BACKGROUND Computer clinical decision support (CDS) systems are uncommon in the pediatric intensive care unit (PICU), despite evidence suggesting they improve outcomes in adult ICUs. We reasoned that a bedside CDS protocol for intravenous insulin titration, eProtocol-insulin, would be feasible and safe in critically ill children. METHODS We retrospectively reviewed data from non-diabetic children admitted to the PICU with blood glucose (BG) ≥140 mg/dL who were managed with intravenous insulin by either unaided clinician titration or eProtocol-insulin. Primary outcomes were BG measurements in target range (80-110 mg/dL) and severe hypoglycemia (BG ≤40 mg/dL); secondary outcomes were 60-day mortality and PICU length of stay. We assessed bedside nurse satisfaction with the eProtocol-insulin protocol by using a 5-point Likert scale and measured clinician compliance with eProtocol-insulin recommendations. RESULTS Over 5 years, 69 children were titrated with eProtocol-insulin versus 104 by unaided clinicians. eProtocol-insulin achieved target range more frequently than clinician titration (41% vs. 32%, P < 0.001). Severe hypoglycemia was uncommon in both groups (4.3% of patients in eProtocol-insulin, 8.7% in clinician titration, P = 0.37). There were no differences in mean time to BG target or median BG between the groups. Mortality was 23% in both groups. Clinician compliance with eProtocol-insulin recommendations was 89%. Nurses believed that eProtocol-insulin was easy to understand and safer than clinician titration. CONCLUSIONS eProtocol-insulin is safe for titration of intravenous insulin in critically ill children. Clinical research protocols and quality improvement initiatives aimed at optimizing BG control should utilize detailed computer protocols that enable replicable clinician decisions.
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Affiliation(s)
- Eliotte L. Hirshberg
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael J. Lanspa
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Emily L. Wilson
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah
| | - Katherine A. Sward
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah
- University of Utah School of Nursing, Salt Lake City, Utah
| | - Al Jephson
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
| | - Gitte Y. Larsen
- Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, Utah
| | - Alan H. Morris
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah
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25
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Agus MSD, Wypij D, Hirshberg EL, Srinivasan V, Faustino EV, Luckett PM, Alexander JL, Asaro LA, Curley MAQ, Steil GM, Nadkarni VM. Tight Glycemic Control in Critically Ill Children. N Engl J Med 2017; 376:729-741. [PMID: 28118549 PMCID: PMC5444653 DOI: 10.1056/nejmoa1612348] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND In multicenter studies, tight glycemic control targeting a normal blood glucose level has not been shown to improve outcomes in critically ill adults or children after cardiac surgery. Studies involving critically ill children who have not undergone cardiac surgery are lacking. METHODS In a 35-center trial, we randomly assigned critically ill children with confirmed hyperglycemia (excluding patients who had undergone cardiac surgery) to one of two ranges of glycemic control: 80 to 110 mg per deciliter (4.4 to 6.1 mmol per liter; lower-target group) or 150 to 180 mg per deciliter (8.3 to 10.0 mmol per liter; higher-target group). Clinicians were guided by continuous glucose monitoring and explicit methods for insulin adjustment. The primary outcome was the number of intensive care unit (ICU)-free days to day 28. RESULTS The trial was stopped early, on the recommendation of the data and safety monitoring board, owing to a low likelihood of benefit and evidence of the possibility of harm. Of 713 patients, 360 were randomly assigned to the lower-target group and 353 to the higher-target group. In the intention-to-treat analysis, the median number of ICU-free days did not differ significantly between the lower-target group and the higher-target group (19.4 days [interquartile range {IQR}, 0 to 24.2] and 19.4 days [IQR, 6.7 to 23.9], respectively; P=0.58). In per-protocol analyses, the median time-weighted average glucose level was significantly lower in the lower-target group (109 mg per deciliter [IQR, 102 to 118]; 6.1 mmol per liter [IQR, 5.7 to 6.6]) than in the higher-target group (123 mg per deciliter [IQR, 108 to 142]; 6.8 mmol per liter [IQR, 6.0 to 7.9]; P<0.001). Patients in the lower-target group also had higher rates of health care-associated infections than those in the higher-target group (12 of 349 patients [3.4%] vs. 4 of 349 [1.1%], P=0.04), as well as higher rates of severe hypoglycemia, defined as a blood glucose level below 40 mg per deciliter (2.2 mmol per liter) (18 patients [5.2%] vs. 7 [2.0%], P=0.03). No significant differences were observed in mortality, severity of organ dysfunction, or the number of ventilator-free days. CONCLUSIONS Critically ill children with hyperglycemia did not benefit from tight glycemic control targeted to a blood glucose level of 80 to 110 mg per deciliter, as compared with a level of 150 to 180 mg per deciliter. (Funded by the National Heart, Lung, and Blood Institute and others; HALF-PINT ClinicalTrials.gov number, NCT01565941 .).
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Affiliation(s)
- Michael S D Agus
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - David Wypij
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - Eliotte L Hirshberg
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - Vijay Srinivasan
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - E Vincent Faustino
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - Peter M Luckett
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - Jamin L Alexander
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - Lisa A Asaro
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - Martha A Q Curley
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - Garry M Steil
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
| | - Vinay M Nadkarni
- From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.)
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Lanspa MJ, Shahul S, Hersh A, Wilson EL, Olsen TD, Hirshberg EL, Grissom CK, Brown SM. Associations among left ventricular systolic function, tachycardia, and cardiac preload in septic patients. Ann Intensive Care 2017; 7:17. [PMID: 28213737 PMCID: PMC5315651 DOI: 10.1186/s13613-017-0240-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 09/21/2016] [Accepted: 02/01/2017] [Indexed: 01/25/2023] Open
Abstract
Background In sepsis, tachycardia may indicate low preload, adrenergic stimulation, or both. Adrenergic overstimulation is associated with septic cardiomyopathy. We sought to determine whether tachycardia was associated with left ventricular longitudinal strain, a measure of cardiac dysfunction. We hypothesized an association would primarily exist in patients with high preload. Methods We prospectively observed septic patients admitted to three study ICUs, who underwent early transthoracic echocardiography. We measured longitudinal strain using speckle tracking echocardiography and estimated preload status with an echocardiographic surrogate (E/e′). We assessed correlation between strain and heart rate in patients with low preload (E/e′ < 8), intermediate preload (E/e′ 8–14), and high preload (E/e′ > 14), adjusting for disease severity and vasopressor dependence. Results We studied 452 patients, of whom 298 had both measurable strain and preload. Abnormal strain (defined as >−17%) was present in 54%. Patients with abnormal strain had higher heart rates (100 vs. 93 beat/min, p = 0.001). After adjusting for vasopressor dependence, disease severity, and cardiac preload, we observed an association between heart rate and longitudinal strain (β = 0.05, p = 0.003). This association persisted among patients with high preload (β = 0.07, p = 0.016) and in patients with shock (β = 0.07, p = 0.01), but was absent in patients with low or intermediate preload and those not in shock. Conclusions Tachycardia is associated with abnormal left ventricular strain in septic patients with high preload. This association was not apparent in patients with low or intermediate preload. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0240-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA. .,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA.
| | - Sajid Shahul
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, Chicago, IL, 60637, USA
| | - Andrew Hersh
- Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA
| | - Troy D Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA
| | - Eliotte L Hirshberg
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA.,Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Colin K Grissom
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 N 1900 E, 701 Wintrobe, Salt Lake City, UT, 84132, USA
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27
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Lanspa MJ, Briggs BJ, Hirshberg EL, Pratt CM, Grissom CK, Brown SM. Data availability and feasibility of various techniques to predict response to volume expansion in critically ill patients. Int J Crit Illn Inj Sci 2017; 7:163-165. [PMID: 28971030 PMCID: PMC5613408 DOI: 10.4103/2229-5151.214412] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: The accuracy of various techniques to predict response to volume expansion in shock has been studied, but less well known is how feasible these techniques are in the ICU. Methods: This is a prospective observation single-center study of inpatients from a mixed profile ICU who received volume expansion. At time of volume expansion, we determined whether a particular technique to predict response was feasible, according to rules developed from available literature and nurse assessment. Results: We studied 214 volume expansions in 97 patients. The most feasible technique was central venous pressure (50%), followed by vena cava collapsibility, (47%) passive leg raise (42%), and stroke volume variation (22%). Aortic velocity variation, and pulse pressure variation, and were rarely feasible (1% each). In 37% of volume expansions, no technique that we assessed was feasible. Conclusions: Techniques to predict response to volume expansion are infeasible in many patients in shock.
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Affiliation(s)
- Michael J Lanspa
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Benjamin J Briggs
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Cristina M Pratt
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Colin K Grissom
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Butler JM, Hirshberg EL, Hopkins RO, Wilson EL, Orme JF, Beesley SJ, Kuttler K, Brown SM. Preliminary Identification of Coping Profiles Relevant to Surrogate Decision Making in the ICU. PLoS One 2016; 11:e0166542. [PMID: 27835704 PMCID: PMC5105941 DOI: 10.1371/journal.pone.0166542] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 10/31/2016] [Indexed: 11/19/2022] Open
Abstract
Objective The Intensive Care Unit (ICU) is a stressful environment for families of critically ill patients and these individuals are at risk to develop persistent psychological morbidity. Our study objective was to identify individual differences in coping with stress and information presentation preferences of respondents exposed to a simulated ICU experience. Methods Participants were recruited from a university and two community populations. Participants completed questionnaires that measured demographic information and characteristics that may be relevant to an individual’s ICU experience. Quality of life was measured by the EQ-5D, personality dimensions were examined with the abbreviated Big Five inventory, coping with stress was assessed with Brief COPE. Shared decision making preferences were assessed by the Degner Control Preferences Scale (CPS) and information seeking style was assessed with the Miller Behavioral Style Scale (MBSS). Social support was examined using an abbreviated version of the Social Relationship Index. Participants also completed a vignette-based simulated ICU experience, in which they made a surrogate decision on behalf of a loved one in the ICU. Results Three hundred forty-three participants completed the study. Three distinct coping profiles were identified: adaptive copers, maladaptive copers, and disengaged copers. Profiles differed primarily on coping styles, personality, quality of their closest social relationship, and history of anxiety and depression. Responses to the simulated ICU decision making experience differed across profiles. Disengaged copers (15%) were more likely to elect to refuse dialysis on behalf of an adult sibling compared to adaptive copers (7%) or maladaptive copers (5%) (p = 0.03). Notably, the MBSS and the CPS did not differ by coping profile. Conclusion Distinct coping profiles are associated with differences in responses to a simulated ICU experience. Tailoring communication and support to specific coping profiles may represent an important pathway to improving ICU experience for patients and families.
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Affiliation(s)
- Jorie M. Butler
- Geriatric Research Education and Clinical Center (GRECC), George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
- Department of Internal Medicine, Division of Geriatrics, University of Utah, Salt Lake City, Utah, United States of America
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- * E-mail:
| | - Eliotte L. Hirshberg
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Department of Internal Medicine, Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah, United States of America
| | - Ramona O. Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah, United States of America
| | - Emily L. Wilson
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
| | - James F. Orme
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Department of Internal Medicine, Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Sarah J. Beesley
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Department of Internal Medicine, Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Kathryn Kuttler
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Homer Warner Center for Informatics Research, Murray, Utah, United States of America
| | - Samuel M. Brown
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, Utah, United States of America
- Department of Medicine, Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah, United States of America
- Department of Internal Medicine, Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah, United States of America
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Abstract
In a recently published issue of Critical Care Medicine, Kar and colleagues investigated glucose management of critically ill patients with type 2 diabetes. In this commentary, we discuss the challenges of investigating glucose control in the critically ill, why so many internally valid studies in this field lead to conflicting results, and the obstacles preventing investigators from reaching a conclusive answer.
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Affiliation(s)
- Sarah J Beesley
- Pulmonary and Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eliotte L Hirshberg
- Pulmonary and Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA;; Pulmonary and Critical Care, Intermountain Medical Center, Murray, Utah, USA
| | - Michael J Lanspa
- Pulmonary and Critical Care, Intermountain Medical Center, Murray, Utah, USA
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Lanspa MJ, Gutsche AR, Wilson EL, Olsen TD, Hirshberg EL, Knox DB, Brown SM, Grissom CK. Application of a simplified definition of diastolic function in severe sepsis and septic shock. Crit Care 2016; 20:243. [PMID: 27487776 PMCID: PMC4973099 DOI: 10.1186/s13054-016-1421-3] [Citation(s) in RCA: 56] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/20/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Left ventricular diastolic dysfunction is common in patients with severe sepsis or septic shock, but the best approach to categorization is unknown. We assessed the association of common measures of diastolic function with clinical outcomes and tested the utility of a simplified definition of diastolic dysfunction against the American Society of Echocardiography (ASE) 2009 definition. METHODS In this prospective observational study, patients with severe sepsis or septic shock underwent transthoracic echocardiography within 24 h of onset of sepsis (median 4.3 h). We measured echocardiographic parameters of diastolic function and used random forest analysis to assess their association with clinical outcomes (28-day mortality and ICU-free days to day 28) and thereby suggest a simplified definition. We then compared patients categorized by the ASE 2009 definition and our simplified definition. RESULTS We studied 167 patients. The ASE 2009 definition categorized only 35 % of patients. Random forest analysis demonstrated that the left atrial volume index and deceleration time, central to the ASE 2009 definition, were not associated with clinical outcomes. Our simplified definition used only e' and E/e', omitting the other measurements. The simplified definition categorized 87 % of patients. Patients categorized by either ASE 2009 or our novel definition had similar clinical outcomes. In both definitions, worsened diastolic function was associated with increased prevalence of ischemic heart disease, diabetes, and hypertension. CONCLUSIONS A novel, simplified definition of diastolic dysfunction categorized more patients with sepsis than ASE 2009 definition. Patients categorized according to the simplified definition did not differ from patients categorized according to the ASE 2009 definition in respect to clinical outcome or comorbidities.
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Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA. .,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA.
| | - Andrea R Gutsche
- Department of Anesthesiology, University of Utah, 30 North 1900 East, 701 Wintrobe, Salt Lake City, UT, 84132, USA
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA
| | - Troy D Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA
| | - Eliotte L Hirshberg
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA.,Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Daniel B Knox
- Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA.,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Massachusetts, 55 Lake Avenue North, Worchester, MA, 01655, USA
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA
| | - Colin K Grissom
- Critical Care Echocardiography Service, Intermountain Medical Center, 5121 South Cottonwood Street, Murray, UT, 84157, USA.,Division of Pulmonary and Critical Care Medicine, University of Utah, 30 North 1900 East, 701 Wintrobe Building, Salt Lake City, UT, 84132, USA
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31
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Lanspa MJ, Pittman JE, Hirshberg EL, Wilson EL, Olsen T, Brown SM, Grissom CK. Association of left ventricular longitudinal strain with central venous oxygen saturation and serum lactate in patients with early severe sepsis and septic shock. Crit Care 2015; 19:304. [PMID: 26321626 PMCID: PMC4553920 DOI: 10.1186/s13054-015-1014-6] [Citation(s) in RCA: 31] [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] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/27/2015] [Indexed: 12/29/2022]
Abstract
INTRODUCTION In septic shock, assessment of cardiac function often relies on invasive central venous oxygen saturation (ScvO2). Ventricular strain is a non-invasive method of assessing ventricular wall deformation and may be a sensitive marker of heart function. We hypothesized that it may have a relationship with ScvO2 and lactate. METHODS We prospectively performed transthoracic echocardiography in patients with severe sepsis or septic shock and measured (1) left ventricular longitudinal strain from a four-chamber view and (2) ScvO2. We excluded patients for whom image quality was inadequate or for whom ScvO2 values were unobtainable. We determined the association between strain and ScvO2 with logistic and linear regression, using covariates of mean arterial pressure, central venous pressure, and vasopressor dose. We determined the association between strain and lactate. We considered strain greater than -17% as abnormal and strain greater than -10% as severely abnormal. RESULTS We studied 89 patients, 68 of whom had interpretable images. Of these patients, 42 had measurable ScvO2. Sixty percent of patients had abnormal strain, and 16% had severely abnormal strain. Strain is associated with low ScvO2 (linear coefficient -1.05, p =0.006; odds ratio 1.23 for ScvO2 <60%, p =0.016). Patients with severely abnormal strain had significantly lower ScvO2 (56.1% vs. 67.5%, p <0.01) and higher lactate (2.7 vs. 1.9 mmol/dl, p =0.04) than those who did not. Strain was significantly different between patients, based on a threshold ScvO2 of 60% (-13.7% vs. -17.2%, p =0.01) but not at 70% (-15.0% vs. -18.2%, p =0.08). CONCLUSIONS Left ventricular strain is associated with low ScvO2 and hyperlactatemia. It may be a non-invasive surrogate for adequacy of oxygen delivery during early severe sepsis or septic shock.
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Affiliation(s)
- Michael J Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Salt Lake City, UT, USA. .,Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Joel E Pittman
- Critical Care Echocardiography Service, Intermountain Medical Center, Salt Lake City, UT, USA.
| | - Eliotte L Hirshberg
- Critical Care Echocardiography Service, Intermountain Medical Center, Salt Lake City, UT, USA. .,Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA. .,Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
| | - Emily L Wilson
- Critical Care Echocardiography Service, Intermountain Medical Center, Salt Lake City, UT, USA.
| | - Troy Olsen
- Critical Care Echocardiography Service, Intermountain Medical Center, Salt Lake City, UT, USA.
| | - Samuel M Brown
- Critical Care Echocardiography Service, Intermountain Medical Center, Salt Lake City, UT, USA. .,Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Colin K Grissom
- Critical Care Echocardiography Service, Intermountain Medical Center, Salt Lake City, UT, USA. .,Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.
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Abstract
Comparisons of processes of care are common in critical care research. Often, these processes are neither explicit nor replicable and this can result in seemingly irreconcilable results. Here, we briefly review the article by Taniguchi and colleagues, who studied liberation from mechanical ventilation by using either a computerized weaning protocol or one driven by respiratory therapists. We discuss the implications of explicit protocols increasing replicability in clinical research.
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Affiliation(s)
- Michael J Lanspa
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S. Cottonwood Street, Murray, UT, 84107, USA. .,Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, 26 North 1900 East, Salt Lake City, UT, 84132, USA.
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.,Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, 26 North 1900 East, Salt Lake City, UT, 84132, USA.,Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Russell R Miller
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.,Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, 26 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Alan H Morris
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.,Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah, 26 North 1900 East, Salt Lake City, UT, 84132, USA
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Brown SM, McBride G, Collingridge DS, Butler JM, Kuttler KG, Hirshberg EL, Jones JP, Hopkins RO, Talmor D, Orme J. Validation of the Intermountain patient perception of quality (PPQ) survey among survivors of an intensive care unit admission: a retrospective validation study. BMC Health Serv Res 2015; 15:155. [PMID: 25889073 PMCID: PMC4429340 DOI: 10.1186/s12913-015-0828-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/30/2015] [Indexed: 11/10/2022] Open
Abstract
Background Patients’ perceptions of the quality of their hospitalization have become important to the American healthcare system. Standard surveys of perceived quality of healthcare do not focus on the Intensive Care Unit (ICU) portion of the stay. Our objective was to evaluate the construct validity and internal consistency of the Intermountain Patient Perception of Quality (PPQ) survey among patients discharged from the ICU. Methods We analyzed prospectively collected results from the ICU PPQ survey of all inpatients at Intermountain Medical Center whose hospitalization included an ICU stay. We employed principal components analysis to determine the constructs present in the PPQ survey, and Cronbach’s alpha to evaluate the internal consistency (reliability) of the items representing each construct. Results We identified 5,680 patients who had completed the PPQ survey. There were three basic domains measured: nursing care, physician care, and overall perception of quality. Most of the variability was explained with the first two principal components. Constructs did not vary by type of respondent. Conclusions The Intermountain ICU PPQ survey demonstrated excellent construct validity across three distinct constructs. This, in addition to its previously established content validity, suggests the utility of the PPQ survey as an assay of the perceived quality of the ICU experience. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0828-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Samuel M Brown
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, USA. .,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT, USA. .,Center for Humanizing Critical Care, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT, USA. .,Shock Trauma ICU, Intermountain Medical Center, 5121 S. Cottonwood Street, Murray, UT, 84107, USA.
| | - Glen McBride
- Strategic Planning and Research, Intermountain Healthcare, 36 S. State St., Salt Lake City, UT, USA.
| | - Dave S Collingridge
- Office of Research, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT, USA.
| | - Jorie M Butler
- Center for Humanizing Critical Care, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT, USA. .,Geriatrics Research Education and Clinical Center (GRECC), Veterans Affairs Medical Center, Salt Lake City, UT, USA. .,Department of Internal Medicine, Geriatrics Division, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT, USA.
| | - Kathryn G Kuttler
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, USA. .,Center for Humanizing Critical Care, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT, USA. .,Homer Warner Center for Informatics Research, Intermountain Healthcare, 5171 South Cottonwood Street, Suite 220, Murray, UT, USA.
| | - Eliotte L Hirshberg
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, USA. .,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT, USA. .,Center for Humanizing Critical Care, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT, USA. .,Pediatric Critical Care, University of Utah, 26 North 1900 East, Salt Lake City, UT, USA.
| | - Jason P Jones
- Kaiser-Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA, USA.
| | - Ramona O Hopkins
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, USA. .,Center for Humanizing Critical Care, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT, USA. .,Psychology Department and Neuroscience Center, Brigham Young University, 1022 SWKT, Provo, UT, USA.
| | - Daniel Talmor
- Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 1 Deaconess Rd, Boston, MA, USA.
| | - James Orme
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, 5121 S Cottonwood St, Murray, UT, USA. .,Pulmonary and Critical Care Medicine, University of Utah School of Medicine, 26 North 1900 East, Salt Lake City, UT, USA. .,Center for Humanizing Critical Care, Intermountain Healthcare, 5121 S Cottonwood St, Murray, UT, USA.
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Grissom CK, Hirshberg EL, Dickerson JB, Brown SM, Lanspa MJ, Liu KD, Schoenfeld D, Tidswell M, Hite RD, Rock P, Miller RR, Morris AH. Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome*. Crit Care Med 2015; 43:288-95. [PMID: 25599463 DOI: 10.1097/ccm.0000000000000715] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In the Fluid and Catheter Treatment Trial (FACTT) of the National Institutes of Health Acute Respiratory Distress Syndrome Network, a conservative fluid protocol (FACTT Conservative) resulted in a lower cumulative fluid balance and better outcomes than a liberal fluid protocol (FACTT Liberal). Subsequent Acute Respiratory Distress Syndrome Network studies used a simplified conservative fluid protocol (FACTT Lite). The objective of this study was to compare the performance of FACTT Lite, FACTT Conservative, and FACTT Liberal protocols. DESIGN Retrospective comparison of FACTT Lite, FACTT Conservative, and FACTT Liberal. Primary outcome was cumulative fluid balance over 7 days. Secondary outcomes were 60-day adjusted mortality and ventilator-free days through day 28. Safety outcomes were prevalence of acute kidney injury and new shock. SETTING ICUs of Acute Respiratory Distress Syndrome Network participating hospitals. PATIENTS Five hundred three subjects managed with FACTT Conservative, 497 subjects managed with FACTT Liberal, and 1,124 subjects managed with FACTT Lite. INTERVENTIONS Fluid management by protocol. MEASUREMENTS AND MAIN RESULTS Cumulative fluid balance was 1,918 ± 323 mL in FACTT Lite, -136 ± 491 mL in FACTT Conservative, and 6,992 ± 502 mL in FACTT Liberal (p < 0.001). Mortality was not different between groups (24% in FACTT Lite, 25% in FACTT Conservative and Liberal, p = 0.84). Ventilator-free days in FACTT Lite (14.9 ± 0.3) were equivalent to FACTT Conservative (14.6 ± 0.5) (p = 0.61) and greater than in FACTT Liberal (12.1 ± 0.5, p < 0.001 vs Lite). Acute kidney injury prevalence was 58% in FACTT Lite and 57% in FACTT Conservative (p = 0.72). Prevalence of new shock in FACTT Lite (9%) was lower than in FACTT Conservative (13%) (p = 0.007 vs Lite) and similar to FACTT Liberal (11%) (p = 0.18 vs Lite). CONCLUSIONS FACTT Lite had a greater cumulative fluid balance than FACTT Conservative but had equivalent clinical and safety outcomes. FACTT Lite is an alternative to FACTT Conservative for fluid management in Acute Respiratory Distress Syndrome.
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Affiliation(s)
- Colin K Grissom
- 1Division of Critical Care Medicine, Intermountain Medical Center, Murray, UT. 2Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT. 3Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT. 4College of Pharmacy, University of Utah, Salt Lake City, UT. 5Division of Nephrology, University of California San Francisco, San Francisco, CA. 6Division of Critical Care Medicine, University of California San Francisco, San Francisco, CA. 7Biostatistics Center, Massachusetts General Hospital, Boston, MA. 8Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, MA. 9Respiratory Institute, Cleveland Clinic, Cleveland, OH. 10Department of Anesthesiology, University of Maryland, Baltimore, MD
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Williams CN, Bratton SL, Hirshberg EL. Computerized decision support in adult and pediatric critical care. World J Crit Care Med 2013; 2:21-8. [PMID: 24701413 PMCID: PMC3953873 DOI: 10.5492/wjccm.v2.i4.21] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/02/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
Computerized decision support (CDS) is the most advanced form of clinical decision support available and has evolved with innovative technologies to provide meaningful assistance to medical professionals. Critical care clinicians are in unique environments where vast amounts of data are collected on individual patients, and where expedient and accurate decisions are paramount to the delivery of quality healthcare. Many CDS tools are in use today among adult and pediatric intensive care units as diagnostic aides, safety alerts, computerized protocols, and automated recommendations for management. Some CDS use have significantly decreased adverse events and improved costs when carefully implemented and properly operated. CDS tools integrated into electronic health records are also valuable to researchers providing rapid identification of eligible patients, streamlining data-gathering and analysis, and providing cohorts for study of rare and chronic diseases through data-warehousing. Although the need for human judgment in the daily care of critically ill patients has limited the study and realization of meaningful improvements in overall patient outcomes, CDS tools continue to evolve and integrate into the daily workflow of clinicians, and will likely provide advancements over time. Through novel technologies, CDS tools have vast potential for progression and will significantly impact the field of critical care and clinical research in the future.
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Lanspa MJ, Hirshberg EL, Phillips GD, Holmen J, Stoddard G, Orme J. Moderate glucose control is associated with increased mortality compared with tight glucose control in critically ill patients without diabetes. Chest 2013; 143:1226-1234. [PMID: 23238456 DOI: 10.1378/chest.12-2072] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Optimal glucose management in the ICU remains unclear. In 2009, many clinicians at Intermountain Healthcare selected a moderate glucose control (90-140 mg/dL) instead of tight glucose control (80-110 mg/dL). We hypothesized that moderate glucose control would affect patients with and without preexisting diabetes differently. METHODS We performed a retrospective cohort analysis of all patients treated with eProtocol-insulin from November 2006 to March 2011, stratifying for diabetes. We performed multivariate logistic regression for 30-day mortality with covariates of age, modified APACHE (Acute Physiology and Chronic Health Evaluation) II score, Charlson Comorbidity score, and target glucose. RESULTS We studied 3,529 patients in 12 different ICUs in eight different hospitals. Patients with diabetes had higher mean glucose (132 mg/dL vs 124 mg/dL) and greater glycemic variability (SD = 41 mg/dL vs 29 mg/dL) than did patients without diabetes (P < .01 for both comparisons). Tight glucose control was associated with increased frequency of moderate and severe hypoglycemia (30.3% and 3.6%) compared with moderate glucose control (14.3% and 2.0%, P < .01 for both). Multivariate analysis demonstrated that the moderate glucose target was independently associated with increased risk of mortality in patients without diabetes (OR, 1.36; 95% CI, 1.01-1.84; P = .05) but decreased risk of mortality in patients with diabetes (OR, 0.65; 95% CI, 0.45-0.93; P = .01). CONCLUSIONS Moderate glucose control (90-140 mg/dL) may confer greater mortality in critically ill patients without diabetes compared with tight glucose control (80-110 mg/dL). A single glucose target does not appear optimal for all critically ill patients. These data have important implications for the design of future interventional trials as well as for the glycemic management of critically ill patients.
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Affiliation(s)
- Michael J Lanspa
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT.
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT; Division of Pediatric Critical Care, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
| | | | - John Holmen
- Homer Warner Center, Intermountain Healthcare, Salt Lake City, UT
| | - Gregory Stoddard
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - James Orme
- Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City, UT
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Brown SM, Lanspa MJ, Jones JP, Kuttler KG, Li Y, Carlson R, Miller RR, Hirshberg EL, Grissom CK, Morris AH. Survival after shock requiring high-dose vasopressor therapy. Chest 2013; 143:664-671. [PMID: 22911566 PMCID: PMC3590882 DOI: 10.1378/chest.12-1106] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 07/26/2012] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Some patients with hypotensive shock do not respond to usual doses of vasopressor therapy. Very little is known about outcomes after high-dose vasopressor therapy (HDV). We sought to characterize survival among patients with shock requiring HDV. We also evaluated the possible utility of stress-dose corticosteroid therapy in these patients. METHODS We conducted a retrospective study of patients with shock requiring HDV in the ICUs of five hospitals from 2005 through 2010. We defined HDV as receipt at any point of ≥ 1 μg/kg/min of norepinephrine equivalent (calculated by summing norepinephrine-equivalent infusion rates of all vasopressors). We report survival 90 days after hospital admission. We evaluated receipt of stress-dose corticosteroids, cause of shock, receipt of CPR, and withdrawal or withholding of life support therapy. RESULTS We identified 443 patients meeting inclusion criteria. Seventy-six (17%) survived. Survival was similar (20%) among the 241 patients with septic shock. Among the 367 nonsurvivors, 254 (69%) experienced withholding/withdrawal of care, and 115 (31%) underwent CPR. Stress-dose corticosteroid therapy was associated with increased survival (P = .01). CONCLUSIONS One in six patients with shock survived to 90 days after HDV. The majority of nonsurvivors died after withdrawal or withholding of life support therapy. A minority of patients underwent CPR. Additionally, stress-dose corticosteroid therapy appears reasonable in patients with shock requiring HDV.
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Affiliation(s)
- Samuel M Brown
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael J Lanspa
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Jason P Jones
- Research and Evaluation, Kaiser-Permanente Southern California, Pasadena, CA
| | - Kathryn G Kuttler
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Homer Warner Center for Informatics Research, Intermountain Medical Center, Murray, UT
| | - Yao Li
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Rick Carlson
- Department of Pharmacy, Intermountain Medical Center, Murray, UT
| | - Russell R Miller
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Eliotte L Hirshberg
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT; Division of Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - Colin K Grissom
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Alan H Morris
- Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Lanspa MJ, Brown SM, Hirshberg EL, Jones JP, Grissom CK. Central venous pressure and shock index predict lack of hemodynamic response to volume expansion in septic shock: a prospective, observational study. J Crit Care 2012; 27:609-15. [PMID: 23084132 DOI: 10.1016/j.jcrc.2012.07.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 07/20/2012] [Accepted: 07/23/2012] [Indexed: 12/20/2022]
Abstract
PURPOSE Volume expansion is a common therapeutic intervention in septic shock, although patient response to the intervention is difficult to predict. Central venous pressure (CVP) and shock index have been used independently to guide volume expansion, although their use is questionable. We hypothesize that a combination of these measurements will be useful. METHODS In a prospective, observational study, patients with early septic shock received 10-mL/kg volume expansion at their treating physician's discretion after brief initial resuscitation in the emergency department. Central venous pressure and shock index were measured before volume expansion interventions. Cardiac index was measured immediately before and after the volume expansion using transthoracic echocardiography. Hemodynamic response was defined as an increase in a cardiac index of 15% or greater. RESULTS Thirty-four volume expansions were observed in 25 patients. A CVP of 8 mm Hg or greater and a shock index of 1 beat min(-1) mm Hg(-1) or less individually had a good negative predictive value (83% and 88%, respectively). Of 34 volume expansions, the combination of both a high CVP and a low shock index was extremely unlikely to elicit hemodynamic response (negative predictive value, 93%; P = .02). CONCLUSIONS Volume expansion in patients with early septic shock with a CVP of 8 mm Hg or greater and a shock index of 1 beat min(-1) mm Hg(-1) or less is unlikely to lead to an increase in cardiac index.
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Affiliation(s)
- Michael J Lanspa
- Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Brown SM, Pittman JE, Hirshberg EL, Jones JP, Lanspa MJ, Kuttler KG, Litwin SE, Grissom CK. Diastolic dysfunction and mortality in early severe sepsis and septic shock: a prospective, observational echocardiography study. Crit Ultrasound J 2012; 4:8. [PMID: 22870900 PMCID: PMC3512479 DOI: 10.1186/2036-7902-4-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [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: 01/09/2012] [Accepted: 04/04/2012] [Indexed: 01/07/2023] Open
Abstract
Background Patients with severe sepsis or septic shock often exhibit significant cardiovascular dysfunction. We sought to determine whether severity of diastolic dysfunction assessed by transthoracic echocardiography (TTE) predicts 28-day mortality. Methods In this prospective, observational study conducted in two intensive care units at a tertiary care hospital, 78 patients (age 53.2 ± 17.1 years; 51% females; mean APACHE II score 23.3 ± 7.4) with severe sepsis or septic shock underwent TTE within 6 h of ICU admission, after 18 to 32 h, and after resolution of shock. Left ventricular (LV) diastolic dysfunction was defined according to modified American Society of Echocardiography 2009 guidelines using E, A, and e’ velocities; E/A and E/e’; and E deceleration time. Systolic dysfunction was defined as an ejection fraction < 45%. Results Twenty-seven patients (36.5%) had diastolic dysfunction on initial echocardiogram, while 47 patients (61.8%) had diastolic dysfunction on at least one echocardiogram. Total mortality was 16.5%. The highest mortality (37.5%) was observed among patients with grade I diastolic dysfunction, an effect that persisted after controlling for age and APACHE II score. At time of initial TTE, central venous pressure (CVP) (11+/- 5 mmHg) did not differ among grades I-III, although patients with grade I received less intravenous fluid. Conclusions LV diastolic dysfunction is common in septic patients. Grade I diastolic dysfunction, but not grades II and III, was associated with increased mortality. This finding may reflect inadequate fluid resuscitation in early sepsis despite an elevated CVP, suggesting a possible role for TTE in sepsis resuscitation.
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Affiliation(s)
- Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, UT, 84132, USA.
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Abstract
BACKGROUND The practice of glycemic control with intravenous insulin in critically ill patients has brought clinical focus on understanding the effects of hypoglycemia, especially in children. Very little is published on the impact of hypoglycemia in this population. We aimed to review the existing literature on hypoglycemia in critically ill neonates and children. METHODS We performed a systematic review of the literature up to August 2011 using PubMed, Ovid MEDLINE and ISI Web of Science using the search terms "hypoglycemia or hypoglyc*" and "critical care or intensive care or critical illness". Articles were limited to "all child (0-18 years old)" and "English". RESULTS A total of 513 articles were identified and 132 were included for review. Hypoglycemia is a significant concern among pediatric and neonatal intensivists. Its definition is complicated by the use of a biochemical measure (i.e., blood glucose) for a pathophysiologic problem (i.e., neuroglycopenia). Based on associated outcomes, we suggest defining hypoglycemia as <40-45 mg/dl in neonates and <60-65 mg/dl in children. Below the suggested threshold values, hypoglycemia is associated with worse neurological outcomes, increased intensive care unit stay, and increased mortality. Disruptions in carbohydrate metabolism increase the risk of hypoglycemia incritically ill children. Prevention of hypoglycemia, especially in the setting of intravenous insulin use, will be best accomplished by the combination of accurate measuring techniques, frequent or continuous glucose monitoring, and computerized insulin titration protocols. CONCLUSION Studies on hypoglycemia in critically ill children have focused on spontaneous hypoglycemia. With the current practice of maintaining blood glucose within a narrow range with intravenous insulin, the risk factors and outcomes associated with insulin-induced hypoglycemia should be rigorously studied to prevent hypoglycemia and potentially improve outcomes of critically ill children.
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Munkwitz M, Hopkins RO, Miller Iii RR, Luckett PM, Hirshberg EL. A perspective on early mobilization for adult patients with respiratory failure: Lessons for the pediatric population. J Pediatr Rehabil Med 2010; 3:215-27. [PMID: 21791852 DOI: 10.3233/prm-2010-0130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To summarize the evidence for early mobilization programs in critically ill pediatric and adult patients with respiratory failure. This paper describes our review of the literature and outlines the morbidities associated with immobility, mechanical ventilation and sedation.The clinical management of acutely ill pediatric patients with respiratory failure traditionally consists of mechanical ventilation, sedation and prolonged immobilization. Although the most severely ill patients require these therapies for survival, each therapy comes with adverse consequences. Early mobilization may reduce complications and confer benefit for children with respiratory failure or those who require prolonged mechanical ventilator support. DESIGN Systematic review of the literature pertaining to early mobilization in pediatric and adult patients with respiratory failure. We searched Medline, PubMed, CINAHL and Cochrane database of controlled trials. Randomized controlled trials (RCTs), observational cohort studies, case control studies and population-based analysis were considered for inclusion. Two reviewers (MM and EH) independently selected pertinent studies. RESULTS No studies of early mobilization in pediatric populations were found. Five adult studies were identified for review; two randomized controlled trials and three observational studies. All studies suggested an improvement in morbidity and economic benefit with implementation of early mobilization. CONCLUSIONS Early mobilization in critically ill adult patients with respiratory failure is associated with a decrease in duration of sedatives, ventilator dependant days, ICU and hospital length of stay. The paucity of studies of early mobilization suggest that implementation of early mobilization is not widely practiced. Studies of early mobilization therapy in the adult patient requiring prolonged mechanical ventilator support are reviewed, and the physiologic rational and observed obstacles to integration of an early mobilization program are discussed. The adult data and scientific evidence are combined to support an opinion about the possible benefits of early mobilization programs. The generalizability of the findings and the feasibility of implementing early mobilization in critically ill children who require prolonged mechanical ventilator support are also considered.
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Affiliation(s)
- Michele Munkwitz
- Department of Pediatrics, Pediatric Critical Care, University of Utah, Primary Children's Medical Center, Salt Lake City, UT, USA
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Miller RR, Markewitz BA, Rolfs RT, Brown SM, Dascomb KK, Grissom CK, Friedrichs MD, Mayer J, Hirshberg EL, Conklin J, Paine R, Dean NC. Clinical findings and demographic factors associated with ICU admission in Utah due to novel 2009 influenza A(H1N1) infection. Chest 2009; 137:752-8. [PMID: 19933372 DOI: 10.1378/chest.09-2517] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Novel 2009 influenza A(H1N1) infection has significantly affected ICUs. We sought to characterize our region's clinical findings and demographic associations with ICU admission due to novel A(H1N1). METHODS We conducted an observational study from May 19, 2009, to June 30, 2009, of descriptive clinical course, inpatient mortality, financial data, and demographic characteristics of an ICU cohort. A case-control study was used to compare the ICU cohort to Salt Lake County residents. RESULTS The ICU cohort of 47 influenza patients had a median age of 34 years, Acute Physiology and Chronic Health Evaluation II score of 21, and BMI of 35 kg/m2. Mortality was 17% (8/47). All eight deaths occurred among the 64% of patients (n = 30) with ARDS, 26 (87%) of whom also developed multiorgan failure. Compared with the Salt Lake County population, patients with novel A(H1N1) were more likely to be obese (22% vs 74%; P < .001), medically uninsured (14% vs 45%; P < .001), and Hispanic (13% vs 23%; P < .01) or Pacific Islander (1% vs 26%; P < .001). Observed ICU admissions were 15-fold greater than expected for those with BMI > or = 40 kg/m2 (standardized morbidity ratio 15.8, 95% CI, 8.3-23.4) and 1.5-fold greater than expected among those with BMI of 30 to 39 kg/m(2) for age-adjusted and sex-adjusted rates for Salt Lake County. CONCLUSIONS Severe ARDS with multiorgan dysfunction in the absence of bacterial infection was a common clinical presentation. In this cohort, young nonwhites without medical insurance were disproportionately likely to require ICU care. Obese patients were particularly susceptible to critical illness due to novel A(H1N1) infection.
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Affiliation(s)
- Russell R Miller
- Intermountain Medical Center, T4S, Respiratory Intensive Care Unit, 5121 S Cottonwood St, Murray, UT 84107, USA.
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Hirshberg EL, Knight S, Larsen GY. HYPERGLYCEMIA IN A HETEROGENEOUS POPULATION OF CRITICALLY ILL CHILDREN. Chest 2005. [DOI: 10.1378/chest.128.4_meetingabstracts.217s] [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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Abstract
CONTEXT Asphyxia is the most common cause of death after avalanche burial. A device that allows a person to breathe air contained in snow by diverting expired carbon dioxide (CO2) away from a 500-cm3 artificial inspiratory air pocket may improve chances of survival in avalanche burial. OBJECTIVE To determine the duration of adequate oxygenation and ventilation during burial in dense snow while breathing with vs without the artificial air pocket device. DESIGN Field study of physiologic respiratory measures during snow burial with and without the device from December 1998 to March 1999. Study burials were terminated at the subject's request, when oxygen saturation as measured by pulse oximetry (SpO2) dropped to less than 84%, or after 60 minutes elapsed. SETTING Mountainous outdoor site at 2385 m elevation, with an average barometric pressure of 573 mm Hg. PARTICIPANTS Six male and 2 female volunteers (mean age, 34.6 years; range, 28-39 years). MAIN OUTCOME MEASURES Burial time, SpO2, partial pressure of end-tidal CO2 (ETCO2), partial pressure of inspiratory CO2 (PICO2), respiratory rate, and heart rate at baseline (in open atmosphere) and during snow burial while breathing with the device and without the device but with a 500-cm3 air pocket in the snow. RESULTS Mean burial time was 58 minutes (range, 45-60 minutes) with the device and 10 minutes (range, 5-14 minutes) without it (P=.001). A mean baseline SpO2 of 96% (range, 90%-99%) decreased to 90% (range, 77%-96%) in those buried with the device (P=.01) and to 84% (range, 79%-92%) in the control burials (P=.02). Only 1 subject buried with the device, but 6 control subjects buried without the device, decreased SpO2 to less than 88% (P=.005). A mean baseline ETCO2 of 32 mm Hg (range, 27-38 mm Hg) increased to 45 mm Hg (range, 32-53 mm Hg) in the burials with the device (P=.02) and to 54 mm Hg (range, 44-63 mm Hg) in the control burials (P=.02). A mean baseline PICO2 of 2 mm Hg (range, 0-3 mm Hg) increased to 32 mm Hg (range, 20-44 mm Hg) in the burials with the device (P=.01) and to 44 mm Hg (range, 37-50 mm Hg) in the control burials (P=.02). Respiratory and heart rates did not change in burials with the device but significantly increased in control burials. CONCLUSIONS In our study, although hypercapnia developed, breathing with the device during snow burial considerably extended duration of adequate oxygenation compared with breathing with an air pocket in the snow. Further study will be needed to determine whether the device improves survival during avalanche burial.
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Affiliation(s)
- C K Grissom
- Pulmonary Division, LDS Hospital, University of Utah, Salt Lake City 84143, USA.
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