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Longino AA, Martin KC, Douglas IS. Monitoring the venous circulation: novel techniques and applications. Curr Opin Crit Care 2024; 30:260-267. [PMID: 38690955 DOI: 10.1097/mcc.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
PURPOSE OF REVIEW Venous pressure is an often-unrecognized cause of patient morbidity. However, bedside assessment of PV is challenging. We review the clinical significance of venous pressure measurement, existing techniques, and introduce the Venous Excess Ultrasound (VExUS) Score as a novel approach using doppler ultrasound to assess venous pressure. RECENT FINDINGS Studies show clear associations between elevated venous pressure and adverse outcomes in critically ill patients. Current venous pressure measurement techniques include physical examination, right heart catheterization (RHC), two-dimensional ultrasound, and a variety of labor-intensive research-focused physiological maneuvers. Each of these techniques have specific shortcomings, limiting their clinical utility. To address these gaps, Beaubien-Souligny et al. introduced the VExUS Score, a novel doppler ultrasound-based method that integrates IVC diameter with doppler measurements of the hepatic, portal, and renal veins to generate a venous congestion assesment. Studies show strong correlations between VExUS score and RHC measurements, and well as an association between VExUS score and improvement in cardiorenal acute kidney injury, diuretic response, and fluid status shifts. However, studies in noncardiac populations have been small, heterogenous, and inconclusive. SUMMARY Early studies evaluating the use of doppler ultrasound to assess venous congestion show promise, but further research is needed in diverse patient populations and clinical settings.
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Affiliation(s)
- August A Longino
- Department of Internal Medicine, University of Colorado Hospital
| | | | - Ivor S Douglas
- Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, CO, USA
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Mart MF, Boehm LM, Kiehl AL, Gong MN, Malhotra A, Owens RL, Khan BA, Pisani MA, Schmidt GA, Hite RD, Exline MC, Carson SS, Hough CL, Rock P, Douglas IS, Feinstein DJ, Hyzy RC, Schweickert WD, Bowton DL, Masica A, Orun OM, Raman R, Pun BT, Strength C, Rolfsen ML, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Ely EW, Jackson JC, Girard TD. Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial. Lancet Respir Med 2024:S2213-2600(24)00077-8. [PMID: 38701817 DOI: 10.1016/s2213-2600(24)00077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes. METHODS This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete. FINDINGS Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo. INTERPRETATION In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults. FUNDING National Institutes of Health and the US Department of Veterans Affairs.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - Leanne M Boehm
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA; Vanderbilt University School of Nursing, Nashville, TN, USA
| | - Amy L Kiehl
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Michelle N Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Department of Medicine, Montefiore Healthcare System/Albert Einstein College of Medicine, New York, NY, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| | - Babar A Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Margaret A Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Gregory A Schmidt
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa, Iowa City, IA, USA
| | - R Duncan Hite
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew C Exline
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Shannon S Carson
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland, OR, USA
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ivor S Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Robert C Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William D Schweickert
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David L Bowton
- Department of Anesthesiology, Section on Critical Care, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Onur M Orun
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Rameela Raman
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Brenda T Pun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Cayce Strength
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Mark L Rolfsen
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Nathan E Brummel
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Christopher G Hughes
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Mayur B Patel
- Section of Surgical Sciences, Division of Acute Care Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Veterans Affairs Tennessee Valley Health System Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - Timothy D Girard
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Douglas IS, Elwan MH, Najarro M, Romagnoli S. Dynamic monitoring tools for patients admitted to the emergency department with circulatory failure: narrative review with panel-based recommendations. Eur J Emerg Med 2024; 31:98-107. [PMID: 38364037 DOI: 10.1097/mej.0000000000001103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Intravenous fluid therapy is commonly administered in the emergency department (ED). Despite the deleterious potential of over- and under-resuscitation, professional society guidelines continue to recommend administering a fixed volume of fluid in initial resuscitation. Predicting whether a specific patient will respond to fluid therapy remains one of the most important, but challenging questions that ED clinicians face in clinical practice. Surrogate parameters (i.e. blood pressure and heart rate), are widely used in usual care to estimate changes in stroke volume (SV). Due to their inadequacy in estimating SV, noninvasive techniques (e.g. bioreactance, echocardiography, noninvasive finger cuff technology), have been proposed as a more accurate and readily deployable method for assessing flow and preload responsiveness. Dynamic monitoring systems based on cardiac preload challenge and assessment of SV, by using noninvasive and continuous methods, provide more accurate, feasible, efficient, and reasonably accurate strategy for prediction of fluid responsiveness than static measurements. In this article, we aimed to analyze the different methods currently available for dynamic monitoring of preload responsiveness.
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Affiliation(s)
- Ivor S Douglas
- Denver Health Medical Center, University of Colorado School of Medicine, Denver Colorado, USA
| | - Mohammed H Elwan
- Emergency Department, Kettering General Hospital, Kettering, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Emergency Medicine, Alexandria University, Alexandria, Egypt
| | - Marta Najarro
- Emergency Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Stefano Romagnoli
- Health Science Department, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy
- Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Tea K, Zu Y, Chung CH, Pagliaro J, Espinoza-Barrera D, Mehta P, Grewal H, Douglas IS, Khan YA, Shaffer JG, Denson JL. The Relationship Between Metabolic Syndrome and Mortality Among Patients With Acute Respiratory Distress Syndrome in Acute Respiratory Distress Syndrome Network and Prevention and Early Treatment of Acute Lung Injury Network Trials. Crit Care Med 2024; 52:407-419. [PMID: 37909824 PMCID: PMC10922467 DOI: 10.1097/ccm.0000000000006092] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Metabolic syndrome is known to predict outcomes in COVID-19 acute respiratory distress syndrome (ARDS) but has never been studied in non-COVID-19 ARDS. We therefore aimed to determine the association of metabolic syndrome with mortality among ARDS trial subjects. DESIGN Retrospective cohort study of ARDS trials' data. SETTING An ancillary analysis was conducted using data from seven ARDS Network and Prevention and Early Treatment of Acute Lung Injury Network randomized trials within the Biologic Specimen and Data Repository Information Coordinating Center database. PATIENTS Hospitalized patients with ARDS and metabolic syndrome (defined by obesity, diabetes, and hypertension) were compared with similar patients without metabolic syndrome (those with less than three criteria). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was 28-day mortality. Among 4288 ARDS trial participants, 454 (10.6%) with metabolic syndrome were compared with 3834 controls (89.4%). In adjusted analyses, the metabolic syndrome group was associated with lower 28-day and 90-day mortality when compared with control (adjusted odds ratio [aOR], 0.70 [95% CI, 0.55-0.89] and 0.75 [95% CI, 0.60-0.95], respectively). With each additional metabolic criterion from 0 to 3, adjusted 28-day mortality was reduced by 18%, 22%, and 40%, respectively. In subgroup analyses stratifying by ARDS etiology, mortality was lower for metabolic syndrome vs. control in ARDS caused by sepsis or pneumonia (at 28 d, aOR 0.64 [95% CI, 0.48-0.84] and 90 d, aOR 0.69 [95% CI, 0.53-0.89]), but not in ARDS from noninfectious causes (at 28 d, aOR 1.18 [95% CI, 0.70-1.99] and 90 d, aOR 1.26 [95% CI, 0.77-2.06]). Interaction p = 0.04 and p = 0.02 for 28- and 90-day comparisons, respectively. CONCLUSIONS Metabolic syndrome in ARDS was associated with a lower risk of mortality in non-COVID-19 ARDS. The relationship between metabolic inflammation and ARDS may provide a novel biological pathway to be explored in precision medicine-based trials.
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Affiliation(s)
- Kevin Tea
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Yuanhao Zu
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Cheng Han Chung
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Jaclyn Pagliaro
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Diana Espinoza-Barrera
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Prakriti Mehta
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Himmat Grewal
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
| | - Ivor S Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, Denver Health Medical Center, Denver, CO
| | - Yasin A Khan
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jeffrey G Shaffer
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA
| | - Joshua L Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA
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Longino A, Martin K, Leyba K, Siegel G, Thai TN, Riscinti M, Douglas IS, Gill E, Burke J. Prospective Evaluation of Venous Excess Ultrasound for Estimation of Venous Congestion. Chest 2024; 165:590-600. [PMID: 37813180 DOI: 10.1016/j.chest.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/24/2023] [Accepted: 09/29/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Venous excess ultrasound (VExUS) is a novel ultrasound technique previously reported as a noninvasive measure of venous congestion and predictor of cardiorenal acute kidney injury. RESEARCH QUESTION Are there associations between VExUS grade and cardiac pressures measured by right heart catheterization (RHC) and cardiac biomarkers and clinical outcomes in patients undergoing RHC? STUDY DESIGN AND METHODS We conducted a prospective cohort study at the Denver Health Medical Center from December 20, 2022, to March 25, 2023. All patients undergoing RHC underwent a blinded VExUS assessment prior to their procedure. Multivariable regressions were conducted to assess relationships between VExUS grade and cardiac pressures, biomarkers, and changes in weight among patients with heart failure, a proxy for diuretic success. Receiver operating characteristic curve and area under the curve (AUC) were derived for VExUS, inferior vena cava (IVC) diameter, and IVC collapsibility index (ICI) to predict right atrial pressure (RAP) > 10 and < 7 mm Hg. RESULTS Among 81 patients, 45 of whom were inpatients, after adjusting for age, sex, and Charlson Comorbidity Index, there were significant relationships between VexUS grade of 2 (β = 4.8; 95% CI, 2.6-7.1; P < .01) and 3 (β = 11; 95% CI, 8.9-14; P < .01) and RAP, VExUS grade of 2 (β = 6.8; 95% CI, 0.16-13; P = .045) and 3 (β = 15; 95% CI, 7.3-22; P < .01) and mean pulmonary artery pressure, and VExUS grade of 2 (β = 7.0; 95% CI, 3.9-10; P < .01) and 3 (β = 13; 95% CI, 9.5-17; P < .01) and pulmonary capillary wedge pressure. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP > 10 mm Hg were 0.9 (95% CI, 0.83-0.97), 0.77 (95% CI, 0.68-0.88), and 0.65 (95% CI, 0.52-0.78), respectively. AUC values for VExUS, IVC diameter, and ICI as predictors of RAP < 7 mm Hg were 0.79 (95% CI, 0.70-0.87), 0.74 (95% CI, 0.64-0.84), and 0.62 (95% CI, 0.49-0.76), respectively. In a subset of 23 patients with heart failure undergoing diuresis, there was a significant association between VExUS grade 3 and change in weight between time of RHC and discharge (P = .025). INTERPRETATION Although more research is required, VExUS has the potential to increase diagnostic and therapeutic capabilities of physicians at the bedside and increase our understanding of the underappreciated problem of venous congestion.
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Affiliation(s)
- August Longino
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO.
| | - Katie Martin
- University of Colorado School of Medicine, University of Colorado, Aurora, CO
| | - Katarina Leyba
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO
| | - Gabriel Siegel
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO
| | - Theresa N Thai
- Department of Cardiology, University of Colorado, Aurora, CO
| | - Matthew Riscinti
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO
| | - Ivor S Douglas
- Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, CO
| | - Edward Gill
- Department of Cardiology, University of Colorado, Aurora, CO
| | - Joseph Burke
- Department of Cardiology, Denver Health Medical Center, Denver, CO
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Mehta AB, Douglas IS, Battaglia C, Wynia MK. Utilization of Hospital Do-Not-Resuscitate Orders in Older Adults During COVID-19 Surges in 2020. J Palliat Med 2024; 27:201-208. [PMID: 37616551 PMCID: PMC10908317 DOI: 10.1089/jpm.2023.0277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
Background: Reports of poor outcomes among older adults with COVID-19 may have changed patient perceptions of Do-Not-Resuscitate (DNR) orders or caused providers to pressure older adults into accepting DNR orders to conserve resources. Objective: We determined early-DNR utilization during COVID-19 surges compared with nonsurge periods among nonsurgical adults ≥75 and its connection to hospital mortality. Methods: We conducted a retrospective cohort study among adults ≥75 years using the California Patient Discharge Database 2020. The primary outcome was early-DNR utilization. Control cohorts included nonsurgical adults <75 years in 2020 and nonsurgical adults ≥75 in 2019. Multiple causal inference methods were used to address measured and unmeasured confounding. Results: A total of 487,955 adults ≥75 years were identified, with 233,678 admitted during COVID-19 surges. Older adults admitted during surges had higher rates of early-DNR orders (30.1% vs. 29.4%, absolute risk differences = 0.7, 95% confidence interval [CI]: 0.5-1.0) even after adjusting for patient case-mix (adjusted odds ratio [aOR] = 1.02, 95% CI: 1.01-1.04). Patients with early-DNR orders experienced higher hospital mortality (15.5% vs. 4.8%, aOR = 3.96, 95% CI: 3.85-4.06). Difference-in-difference analyses demonstrated that adults <75 years in 2020 and adults ≥75 years in 2019 did not experience variation in early-DNR utilization. Conclusions: Older adults had slightly higher rates of early-DNR orders during COVID-19 surges compared with nonsurge periods. While the difference in early-DNR utilization was small, it was linked to higher odds of death. The increase in early-DNR use only during COVID-19 surges and only among older adults may reflect changes in patient preferences or increased pressure on older adults stemming from provider fears of rationing during COVID-19 surges.
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Affiliation(s)
- Anuj B. Mehta
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Association, Denver, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado, USA
- Center for Bioethics and Humanities, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ivor S. Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Association, Denver, Colorado, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Catherine Battaglia
- Department of Health System Management and Policy, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado, USA
- Department of Veteran Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Matthew K. Wynia
- Center for Bioethics and Humanities, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Health System Management and Policy, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Mehta AB, Lockhart S, Lange AV, Matlock DD, Douglas IS, Morris MA. Drivers of Decision-Making for Adult Tracheostomy for Prolonged Mechanical Ventilation: A Qualitative Study. medRxiv 2024:2024.01.20.24301492. [PMID: 38293156 PMCID: PMC10827243 DOI: 10.1101/2024.01.20.24301492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Background Decision-making about tracheostomy and prolonged mechanical ventilation (PMV) is emotionally complex. Expectations of surrogate decision-makers and physicians rarely align. Little is known about what surrogates need to make goal-concordant decisions. We sought to identify drivers of tracheostomy and PMV decision-making. Methods Using Grounded Theory, we performed a qualitative study with semi-structured interviews with surrogates of patients receiving mechanical ventilation (MV) being considered for tracheostomy and physicians routinely caring for patients receiving MV. Recruitment was stopped when thematic saturation was reached. Separate codebooks were created for surrogate and physician interviews. Themes and factors affecting decision-making were identified and a theoretical model tracheostomy decision-making was developed. Results 43 participants (23 surrogates and 20 physicians) completed interviews. A theoretical model of themes and factors driving decision-making emerged for the data. Hope, Lack of Knowledge & Data, and Uncertainty emerged as the three main themes all which were interconnected with one another and, at times, opposed each other. Patient Wishes, Past Activity/Medical History, Short and Long-Term Outcomes, and Meaningful Recovery were key factors upon which surrogates and physicians based decision-making. The themes were the lens through which the factors were viewed and decision-making existed as a balance between surrogate emotions and understanding and physician recommendations. Conclusions Tracheostomy and prolonged MV decision-making is complex. Hope and Uncertainty were conceptual themes that often battled with one another. Lack of Knowledge & Data plagued both surrogates and physicians. Multiple tangible factors were identified that affected surrogate decision-making and physician recommendations. Implications Understanding this complex decision-making process has the potential to improve the information provided to surrogates and, potentially, increase the goal concordant care and alignment of surrogate and physician expectations. Highlights Decision-making for tracheostomy and prolonged mechanical ventilation is a complex interactive process between surrogate decision-makers and providers.Using a Grounded Theory framework, a theoretical model emerged from the data with core themes of Hope, Uncertainty, and Lack of Knowledge & Data that was shared by both providers and surrogates.The core themes were the lenses through which the key decision-making factors of Patient Wishes, Past Activity/Medical History, Short and Long-Term Outcomes, and Meaningful Recovery were viewed.The theoretical model provides a roadmap to design a shared decision-making intervention to improve tracheostomy and prolonged mechanical ventilation decision-making.
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Khader A, Zelnick LR, Sathe NA, Kestenbaum BR, Himmelfarb J, Johnson NJ, Shapiro NI, Douglas IS, Hough CL, Bhatraju PK. The Interaction of Acute Kidney Injury with Resuscitation Strategy in Sepsis: A Secondary Analysis of a Multicenter, Phase 3, Randomized Clinical Trial (CLOVERS). Am J Respir Crit Care Med 2023; 208:1335-1338. [PMID: 37870416 PMCID: PMC10765399 DOI: 10.1164/rccm.202308-1448le] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/20/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Ayesha Khader
- Division of Pulmonary, Critical Care and Sleep Medicine
| | - Leila R. Zelnick
- Kidney Research Institute, Division of Nephrology, Department of Medicine
| | - Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine
| | | | | | - Nicholas J. Johnson
- Division of Pulmonary, Critical Care and Sleep Medicine
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ivor S. Douglas
- Pulmonary Science and Critical Care Medicine, Denver Health Medical Center and University of Colorado, Anschutz Medical Campus, Denver, Colorado; and
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, Oregon
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine
- Kidney Research Institute, Division of Nephrology, Department of Medicine
- Sepsis Center of Research Excellence, and
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Mehta AB, Matlock DD, Shorr AF, Douglas IS. Healthcare Trajectories and Outcomes in the First Year After Tracheostomy Based on Patient Characteristics. Crit Care Med 2023; 51:1727-1739. [PMID: 37638787 DOI: 10.1097/ccm.0000000000006029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVES To define healthcare trajectories after tracheostomy to inform shared decision-making efforts for critically ill patients. DESIGN Retrospective epidemiologic cohort study. SETTING California Patient Discharge Database 2018-2019. PATIENTS Patients who received a tracheostomy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tracked 1-year outcomes after tracheostomy, including survival and time alive in and out of a healthcare facility (HCF. Patients were stratified based on surgical status (did the patient require a major operating room procedure or not), age (65 yr old or older and less than 65 yr), pre-ICU comorbid states (frailty, chronic organ dysfunction, cancer, and robustness), and the need for dialysis during the tracheostomy admission. We identified 4,274 nonsurgical adults who received a tracheostomy during the study period with 50.9% being 65 years old or older. Among adults 65 years old or older, median survival after tracheostomy was less than 3 months for individuals with frailty, chronic organ dysfunction, cancer, or dialysis. Median survival was 3 months for adults younger than 65 years with cancer or dialysis. Most patients spent the majority of days alive after a tracheostomy in an HCF in the first 3 months. Older adults had very few days alive and out of an HCF in the first 3 months after tracheostomy. Most patients who ultimately died in the first year after tracheostomy spent almost all days alive in an HCF. CONCLUSIONS Cumulative mortality and median survival after a tracheostomy were very poor across most ages and groups. Older adults and several subgroups of younger adults experienced high rates of prolonged hospitalization with few days alive and out of an HCF. This information may aid some patients, surrogates, and providers in decision-making.
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Affiliation(s)
- Anuj B Mehta
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Veteran's Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Aurora, CO
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
- Department of Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Daniel D Matlock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Veteran's Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Aurora, CO
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
- Department of Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Andrew F Shorr
- Department of Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Ivor S Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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Rai K, Douglas IS, Mehta AB. Association of Hospital Mortality With Initiation of Mechanical Ventilation on a Weekend: A Retrospective Cohort Study. J Intensive Care Med 2023; 38:1136-1142. [PMID: 37357730 DOI: 10.1177/08850666231185315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
RATIONALE Increased mortality in patients admitted to hospitals on weekends is a well-described phenomenon labeled the "weekend effect." Studies evaluating the weekend effect in intensive care units (ICUs) have arrived at conflicting results. Identifying a weekend effect for critically-ill patients may inform clinical care pathways and resource allocation. OBJECTIVES Determine the association of initiation of mechanical ventilation (MV) upon admission on a weekend versus weekday with hospital mortality. METHODS We conducted a retrospective cohort study of non-surgical adult patients using the California Patient Discharge Database from 2018 to 2019. We identified MV initiated on the day of admission and diagnoses using discharge billing codes. The primary exposure was admission and initiation of MV on a weekend versus weekday and the primary outcome was hospital mortality. Hierarchical logistic regression was used to determine the association between hospital mortality and MV initiation timing, adjusting for case-mix. RESULTS Among 90 288 admissions in 2018 and 2019 meeting inclusion criteria, 24 771 (27.5%) had MV initiated on weekends, while 65 517 (72.6%) had MV initiated on weekdays. Patient demographics and comorbidities were similar between groups. Chronic alcohol and substance use disorders, and acute intoxications and traumas were more prevalent among patients with MV initiated on weekends. No difference in hospital mortality was observed with initiation of MV on weekends versus weekdays (23.1% vs 22.8%, ARD = 0.3%, aOR = 1.02, 95% CI 0.98, 1.07). CONCLUSIONS Contrary to prior studies, no increased mortality was observed among newly admitted patients initiated on MV on weekends compared to weekdays. While weekend effects may exist in other settings, newly admitted patients likely have MV initiated in the emergency department or ICU, which tend to have more consistent staffing levels. Further research is needed to determine if care patterns in these units could be used as a model for units where weekend effects continue to impact outcomes.
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Affiliation(s)
- Karan Rai
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ivor S Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anuj B Mehta
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Finn E, Schlichting L, Grau L, Douglas IS, Pereira RI. Real-world Accuracy of CGM in Inpatient Critical and Noncritical Care Settings at a Safety-Net Hospital. Diabetes Care 2023; 46:1825-1830. [PMID: 37561954 PMCID: PMC10516250 DOI: 10.2337/dc23-0089] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/20/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE We sought to determine real-world accuracy of inpatient continuous glucose monitoring (CGM) at multiple levels of acuity in a large safety-net hospital. RESEARCH DESIGN AND METHODS We analyzed records from hospitalized patients on Dexcom G6 CGM, including clinical, point of care (POC), and laboratory (Lab) glucose, and CGM data. POC/Lab values were matched to the closest timed CGM value. Encounters were divided into not critically ill (NCI) versus critically ill (CI). CGM accuracy was evaluated. RESULTS Paired readings (2,744 POC-CGM; 3,705 Lab-CGM) were analyzed for 233 patients with 239 encounters (83 NCI, 156 CI). POC-CGM aggregated and average mean absolute relative differences (MARD) were 15.1% and 17.1%. Lab-CGM aggregated and average MARDs were 11.4% and 12.2%. Accuracy for POC-CGM and Lab-CGM was 96.5% and 99.1% in Clarke Error Grid zones A/B. CONCLUSIONS Real-world accuracy of inpatient CGM is acceptable for NCI and CI patients. Further exploration of conditions associated with lower CGM accuracy in real-world settings is warranted.
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Affiliation(s)
- Erin Finn
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado, Aurora, CO
| | | | - Laura Grau
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Ivor S. Douglas
- Medicine Service, Denver Health and Hospital Authority, Denver, CO
- Department of Medicine, Pulmonary Science, and Critical Care Medicine, University of Colorado, Aurora, CO
| | - Rocio I. Pereira
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado, Aurora, CO
- Medicine Service, Denver Health and Hospital Authority, Denver, CO
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Brown SM, Barkauskas CE, Grund B, Sharma S, Phillips AN, Leither L, Peltan ID, Lanspa M, Gilstrap DL, Mourad A, Lane K, Beitler JR, Serra AL, Garcia I, Almasri E, Fayed M, Hubel K, Harris ES, Middleton EA, Barrios MAG, Mathews KS, Goel NN, Acquah S, Mosier J, Hypes C, Salvagio Campbell E, Khan A, Hough CL, Wilson JG, Levitt JE, Duggal A, Dugar S, Goodwin AJ, Terry C, Chen P, Torbati S, Iyer N, Sandkovsky US, Johnson NJ, Robinson BRH, Matthay MA, Aggarwal NR, Douglas IS, Casey JD, Hache-Marliere M, Georges Youssef J, Nkemdirim W, Leshnower B, Awan O, Pannu S, O'Mahony DS, Manian P, Awori Hayanga JW, Wortmann GW, Tomazini BM, Miller RF, Jensen JU, Murray DD, Bickell NA, Zatakia J, Burris S, Higgs ES, Natarajan V, Dewar RL, Schechner A, Kang N, Arenas-Pinto A, Hudson F, Ginde AA, Self WH, Rogers AJ, Oldmixon CF, Morin H, Sanchez A, Weintrob AC, Cavalcanti AB, Davis-Karim A, Engen N, Denning E, Taylor Thompson B, Gelijns AC, Kan V, Davey VJ, Lundgren JD, Babiker AG, Neaton JD, Lane HC. Intravenous aviptadil and remdesivir for treatment of COVID-19-associated hypoxaemic respiratory failure in the USA (TESICO): a randomised, placebo-controlled trial. Lancet Respir Med 2023; 11:791-803. [PMID: 37348524 PMCID: PMC10527239 DOI: 10.1016/s2213-2600(23)00147-9] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND There is a clinical need for therapeutics for COVID-19 patients with acute hypoxemic respiratory failure whose 60-day mortality remains at 30-50%. Aviptadil, a lung-protective neuropeptide, and remdesivir, a nucleotide prodrug of an adenosine analog, were compared with placebo among patients with COVID-19 acute hypoxaemic respiratory failure. METHODS TESICO was a randomised trial of aviptadil and remdesivir versus placebo at 28 sites in the USA. Hospitalised adult patients were eligible for the study if they had acute hypoxaemic respiratory failure due to confirmed SARS-CoV-2 infection and were within 4 days of the onset of respiratory failure. Participants could be randomly assigned to both study treatments in a 2 × 2 factorial design or to just one of the agents. Participants were randomly assigned with a web-based application. For each site, randomisation was stratified by disease severity (high-flow nasal oxygen or non-invasive ventilation vs invasive mechanical ventilation or extracorporeal membrane oxygenation [ECMO]), and four strata were defined by remdesivir and aviptadil eligibility, as follows: (1) eligible for randomisation to aviptadil and remdesivir in the 2 × 2 factorial design; participants were equally randomly assigned (1:1:1:1) to intravenous aviptadil plus remdesivir, aviptadil plus remdesivir matched placebo, aviptadil matched placebo plus remdesvir, or aviptadil placebo plus remdesivir placebo; (2) eligible for randomisation to aviptadil only because remdesivir was started before randomisation; (3) eligible for randomisation to aviptadil only because remdesivir was contraindicated; and (4) eligible for randomisation to remdesivir only because aviptadil was contraindicated. For participants in strata 2-4, randomisation was 1:1 to the active agent or matched placebo. Aviptadil was administered as a daily 12-h infusion for 3 days, targeting 600 pmol/kg on infusion day 1, 1200 pmol/kg on day 2, and 1800 pmol/kg on day 3. Remdesivir was administered as a 200 mg loading dose, followed by 100 mg daily maintenance doses for up to a 10-day total course. For participants assigned to placebo for either agent, matched saline placebo was administered in identical volumes. For both treatment comparisons, the primary outcome, assessed at day 90, was a six-category ordinal outcome: (1) at home (defined as the type of residence before hospitalisation) and off oxygen (recovered) for at least 77 days, (2) at home and off oxygen for 49-76 days, (3) at home and off oxygen for 1-48 days, (4) not hospitalised but either on supplemental oxygen or not at home, (5) hospitalised or in hospice care, or (6) dead. Mortality up to day 90 was a key secondary outcome. The independent data and safety monitoring board recommended stopping the aviptadil trial on May 25, 2022, for futility. On June 9, 2022, the sponsor stopped the trial of remdesivir due to slow enrolment. The trial is registered with ClinicalTrials.gov, NCT04843761. FINDINGS Between April 21, 2021, and May 24, 2022, we enrolled 473 participants in the study. For the aviptadil comparison, 471 participants were randomly assigned to aviptadil or matched placebo. The modified intention-to-treat population comprised 461 participants who received at least a partial infusion of aviptadil (231 participants) or aviptadil matched placebo (230 participants). For the remdesivir comparison, 87 participants were randomly assigned to remdesivir or matched placebo and all received some infusion of remdesivir (44 participants) or remdesivir matched placebo (43 participants). 85 participants were included in the modified intention-to-treat analyses for both agents (ie, those enrolled in the 2 x 2 factorial). For the aviptadil versus placebo comparison, the median age was 57 years (IQR 46-66), 178 (39%) of 461 participants were female, and 246 (53%) were Black, Hispanic, Asian or other (vs 215 [47%] White participants). 431 (94%) of 461 participants were in an intensive care unit at baseline, with 271 (59%) receiving high-flow nasal oxygen or non-invasive ventiliation, 185 (40%) receiving invasive mechanical ventilation, and five (1%) receiving ECMO. The odds ratio (OR) for being in a better category of the primary efficacy endpoint for aviptadil versus placebo at day 90, from a model stratified by baseline disease severity, was 1·11 (95% CI 0·80-1·55; p=0·54). Up to day 90, 86 participants in the aviptadil group and 83 in the placebo group died. The cumulative percentage who died up to day 90 was 38% in the aviptadil group and 36% in the placebo group (hazard ratio 1·04, 95% CI 0·77-1·41; p=0·78). The primary safety outcome of death, serious adverse events, organ failure, serious infection, or grade 3 or 4 adverse events up to day 5 occurred in 146 (63%) of 231 patients in the aviptadil group compared with 129 (56%) of 230 participants in the placebo group (OR 1·40, 95% CI 0·94-2·08; p=0·10). INTERPRETATION Among patients with COVID-19-associated acute hypoxaemic respiratory failure, aviptadil did not significantly improve clinical outcomes up to day 90 when compared with placebo. The smaller than planned sample size for the remdesivir trial did not permit definitive conclusions regarding safety or efficacy. FUNDING National Institutes of Health.
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Affiliation(s)
- Samuel M Brown
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA; Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Christina E Barkauskas
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Birgit Grund
- School of Statistics, University of Minnesota, Minneapolis, MN, USA
| | - Shweta Sharma
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Lindsay Leither
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA; Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Ithan D Peltan
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA; Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Michael Lanspa
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA; Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Daniel L Gilstrap
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ahmad Mourad
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Kathleen Lane
- Surgical Office of Clinical Research, Cardiothoracic Surgical Division, Duke University School of Medicine, Durham, NC, USA
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Alexis L Serra
- Columbia Respiratory Critical Care Trials Group and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Ivan Garcia
- Columbia Respiratory Critical Care Trials Group and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Eyad Almasri
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, UCSF Fresno, Fresno, CA, USA
| | - Mohamed Fayed
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, UCSF Fresno, Fresno, CA, USA
| | - Kinsley Hubel
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, UCSF Fresno, Fresno, CA, USA
| | - Estelle S Harris
- Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Elizabeth A Middleton
- Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Macy A G Barrios
- Department of Medicine, Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Neha N Goel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel Acquah
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jarrod Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ; Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ; Banner University Medical Center- Tucson, Tucson, AZ, USA
| | - Cameron Hypes
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ; Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ
| | | | - Akram Khan
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Catherine L Hough
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer G Wilson
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland OH, USA
| | - Siddharth Dugar
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland OH, USA
| | - Andrew J Goodwin
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Charles Terry
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Peter Chen
- Women's Guild Lung Institute, Department of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sam Torbati
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nithya Iyer
- Division of of Pulmonary/Critical Care and Sleep Medicine, Department of Medicine, Baylor University Medical Center, Dallas, TX, USA; Texas A&M School of Medicine, Dallas, TX, USA
| | - Uriel S Sandkovsky
- Division of Infectious Diseases, Department of Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington Harborview Medical Center, Seattle, WA, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Harborview Medical Center, Seattle, WA, USA
| | - Bryce R H Robinson
- Department of Surgery, University of Washington Harborview Medical Center, Seattle, WA, USA
| | - Michael A Matthay
- Cardiovascular Research Institute and Departments of Medicine and Anesthesia, University of California-San Francisco, San Francisco, CA, USA
| | - Neil R Aggarwal
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ivor S Douglas
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Jonathan D Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manuel Hache-Marliere
- Jacobi Medical Center, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - J Georges Youssef
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY, USA; JC Walter Jr Transplant Center Advanced Lung Diseases Program, Houston Methodist Hospital, Houston, TX, USA
| | - William Nkemdirim
- Jacobi Medical Center, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Brad Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Omar Awan
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, VA Medical Center and George Washington University, Washington, DC, USA
| | - Sonal Pannu
- Department of Medicine, Division of Pulmonary Critical Care and Sleep, Ohio State University, Columbus, OH, USA
| | | | - Prasad Manian
- Division of Pulmonary and Critical Medicine, Baylor College of Medicine, Texas Heart Institute, Houston, TX, USA
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery. Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Glenn W Wortmann
- Infectious Diseases Section, MedStar Washington Hospital Center and Georgetown University, Washington, DC, USA
| | - Bruno M Tomazini
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil; HCor Research Institute, São Paulo, Brazil
| | - Robert F Miller
- Institute for Global Health, University College London, London, UK
| | - Jens-Ulrik Jensen
- Section of Respiratory Medicine, Department of Medicine, Herlev-Gentofte Hospital, Hellerup, Denmark; CHIP, Centre of Excellence for Health, Immunity and Infections, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel D Murray
- CHIP, Centre of Excellence for Health, Immunity and Infections, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nina A Bickell
- Department of Population Health Science and Policy and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jigna Zatakia
- Department of Medicine, Division of Pulmonary Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Burris
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elizabeth S Higgs
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Ven Natarajan
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Robin L Dewar
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Adam Schechner
- Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Nayon Kang
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Alejandro Arenas-Pinto
- Institute for Global Health, University College London, London, UK; The Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Fleur Hudson
- The Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angela J Rogers
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Cathryn F Oldmixon
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Haley Morin
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Adriana Sanchez
- Infectious Diseases Section, Veteran Affairs Medical Center, Washington, DC, USA
| | - Amy C Weintrob
- Infectious Diseases Section, Veteran Affairs Medical Center, Washington, DC, USA
| | | | - Anne Davis-Karim
- Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center, Office of Research & Development, Department of Veterans Affairs, Albuquerque, NM, USA
| | - Nicole Engen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Eileen Denning
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital and Harvard Medical School; Boston, MA, USA
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Virginia Kan
- Infectious Diseases Section, Veteran Affairs Medical Center, Washington, DC, USA
| | - Victoria J Davey
- United States Department of Veterans Affairs; Washington, DC, USA
| | - Jens D Lundgren
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Abdel G Babiker
- The Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - H Clifford Lane
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
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Prekker ME, Driver BE, Trent SA, Resnick-Ault D, Seitz KP, Russell DW, Gaillard JP, Latimer AJ, Ghamande SA, Gibbs KW, Vonderhaar DJ, Whitson MR, Barnes CR, Walco JP, Douglas IS, Krishnamoorthy V, Dagan A, Bastman JJ, Lloyd BD, Gandotra S, Goranson JK, Mitchell SH, White HD, Palakshappa JA, Espinera A, Page DB, Joffe A, Hansen SJ, Hughes CG, George T, Herbert JT, Shapiro NI, Schauer SG, Long BJ, Imhoff B, Wang L, Rhoads JP, Womack KN, Janz DR, Self WH, Rice TW, Ginde AA, Casey JD, Semler MW. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med 2023; 389:418-429. [PMID: 37326325 PMCID: PMC11075576 DOI: 10.1056/nejmoa2301601] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [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: 06/17/2023]
Abstract
BACKGROUND Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain. METHODS In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death. RESULTS The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, -3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups. CONCLUSIONS Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE ClinicalTrials.gov number, NCT05239195.).
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Affiliation(s)
- Matthew E Prekker
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Brian E Driver
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Stacy A Trent
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Daniel Resnick-Ault
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Kevin P Seitz
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Derek W Russell
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - John P Gaillard
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Andrew J Latimer
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Shekhar A Ghamande
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Kevin W Gibbs
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Derek J Vonderhaar
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Micah R Whitson
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Christopher R Barnes
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Jeremy P Walco
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Ivor S Douglas
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Vijay Krishnamoorthy
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Alon Dagan
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Jill J Bastman
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Bradley D Lloyd
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Sheetal Gandotra
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Jordan K Goranson
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Steven H Mitchell
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Heath D White
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Jessica A Palakshappa
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Alyssa Espinera
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - David B Page
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Aaron Joffe
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Sydney J Hansen
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Christopher G Hughes
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Tobias George
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - J Taylor Herbert
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Nathan I Shapiro
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Steven G Schauer
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Brit J Long
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Brant Imhoff
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Li Wang
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Jillian P Rhoads
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Kelsey N Womack
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - David R Janz
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Wesley H Self
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Todd W Rice
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Adit A Ginde
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Jonathan D Casey
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
| | - Matthew W Semler
- From the Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (M.E.P., S.J.H.), and the Department of Emergency Medicine (M.E.P., B.E.D.), Hennepin County Medical Center, Minneapolis; the Department of Emergency Medicine (S.A.T.) and the Division of Pulmonary, Critical Care, and Sleep Medicine (I.S.D., T.G.), Denver Health Medical Center, Denver, and the Department of Emergency Medicine (S.A.T., D.R.-A., J.J.B., A.A.G.) and the Department of Medicine, Division of Pulmonary and Critical Care Medicine (I.S.D.), University of Colorado School of Medicine, Aurora; the Department of Medicine, Division of Pulmonary and Critical Care Medicine (K.P.S., T.W.R., J.D.C., M.W.S.), the Departments of Anesthesiology (J.P.W., C.G.H.), Emergency Medicine (B.D.L., W.H.S.), and Biostatistics (B.I., L.W.), and the Vanderbilt Institute for Clinical and Translational Research (J.P.R., K.N.W., W.H.S., T.W.R., M.W.S.), Vanderbilt University Medical Center, Nashville; the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine (D.W.R., M.R.W., S.G., D.B.P.), and the Department of Emergency Medicine (M.R.W.), University of Alabama at Birmingham Heersink School of Medicine, and the Pulmonary Section, Birmingham Veterans Affairs Medical Center (D.W.R.) - both in Birmingham; the Department of Anesthesiology, Section on Critical Care (J.P.G.), and the Department of Emergency Medicine (J.P.G., J.K.G.), Atrium Health Wake Forest Baptist, and the Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine (K.W.G., J.A.P.), Winston-Salem, and the Department of Anesthesiology, Duke University School of Medicine, Durham (V.K., J.T.H.) - all in North Carolina; the Departments of Emergency Medicine (A.J.L., S.H.M.) and Anesthesiology and Critical Care Medicine (C.R.B., A.J.), University of Washington Harborview Medical Center, Seattle; the Department of Medicine, Division of Pulmonary Disease, Critical Care, and Sleep Medicine, Baylor Scott and White Health, Temple (S.A.G., H.D.W.), and the U.S. Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston (S.G.S.), and the 59th Medical Wing, U.S. Air Force, Fort Sam Houston (B.J.L.), San Antonio - all in Texas; the Department of Pulmonary and Critical Care Medicine, Ochsner Health (D.J.V., A.E.), and University Medical Center New Orleans and the Department of Medicine, Section of Pulmonary, Critical Care Medicine, and Allergy and Immunology, Louisiana State University School of Medicine (D.R.J.) - all in New Orleans; and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston (A.D., N.I.S.)
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Mehta AB, Taylor JK, Day G, Lane TC, Douglas IS. Disparities in Adult Patient Selection for Extracorporeal Membrane Oxygenation in the United States: A Population-Level Study. Ann Am Thorac Soc 2023; 20:1166-1174. [PMID: 37021958 PMCID: PMC10405618 DOI: 10.1513/annalsats.202212-1029oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/05/2023] [Indexed: 04/07/2023] Open
Abstract
Rationale: Disparities in patient selection for advanced therapeutics in health care have been identified in multiple studies, but it is unclear if disparities exist in patient selection for extracorporeal membrane oxygenation (ECMO), a rapidly expanding critical care resource. Objectives: To determine if disparities exist in patient selection for ECMO based on sex, primary insurance, and median income of the patient's neighborhood. Methods: In a retrospective cohort study using the Nationwide Readmissions Database 2016-2019, we identified patients treated with mechanical ventilation (MV) and/or ECMO with billing codes. Patient sex, insurance, and income level for patients receiving ECMO were compared with the patients treated with MV only, and hierarchical logistic regression with the hospital as a random intercept was used to determine odds of receiving ECMO based on patient demographics. Results: We identified 2,170,752 MV hospitalizations with 18,725 cases of ECMO. Among patients treated with ECMO, 36.1% were female compared with 44.5% of patients treated with> MV only (adjusted odds ratio [aOR] for ECMO, 0.73; 95% confidence interval [CI], 0.70-0.75). Of patients treated with ECMO, 38.1% had private insurance compared with 17.4% of patients treated with MV only. Patients with Medicaid were less likely to receive ECMO than patients with private insurance (aOR, 0.55; 95% CI, 0.52-0.57). Patients treated with ECMO were more likely to live in the highest-income neighborhoods compared with patients treated with MV only (25.1% vs. 17.3%). Patients living in the lowest-income neighborhoods were less likely to receive ECMO than those living in the highest-income neighborhoods (aOR, 0.63; 95% CI, 0.60-0.67). Conclusions: Significant disparities exist in patient selection for ECMO. Female patients, patients with Medicaid, and patients living in the lowest-income neighborhoods are less likely to be treated with ECMO. Despite possible unmeasured confounding, these findings were robust to multiple sensitivity analyses. On the basis of previous work describing disparities in other areas of health care, we speculate that limited access in some neighborhoods, restrictive/biased interhospital transfer practices, differences in patient preferences, and implicit provider bias may contribute to the observed differences. Future studies with more granular data are needed to identify and modify drivers of observed disparities.
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Affiliation(s)
- Anuj B. Mehta
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Hospital Association, Denver, Colorado; and
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Jennifer K. Taylor
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Gwenyth Day
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor C. Lane
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Ivor S. Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Hospital Association, Denver, Colorado; and
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Longino A, Martin K, Leyba K, Siegel G, Gill E, Douglas IS, Burke J. Correlation between the VExUS score and right atrial pressure: a pilot prospective observational study. Crit Care 2023; 27:205. [PMID: 37237315 DOI: 10.1186/s13054-023-04471-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
Venous congestion is an under-recognized contributor to mortality in critically ill patients. Unfortunately, venous congestion is difficult to measure, and right heart catheterization (RHC) has been considered the most readily available means for measuring venous filling pressure. Recently, a novel "Venous Excess Ultrasound (VExUS)" score was developed to noninvasively quantify venous congestion using inferior vena cava (IVC) diameter and Doppler flow through the hepatic, portal, and renal veins. A preliminary retrospective study of post-cardiac surgery patients showed promising results, including a high positive-likelihood ratio of high VExUS grade for acute kidney injury. However, studies have not been reported in broader patient populations, and the relationship between VExUS and conventional measures of venous congestion is unknown. To address these gaps, we prospectively assessed the correlation of VExUS with right atrial pressure (RAP), with comparison to inferior vena cava (IVC) diameter. Patients undergoing RHC at Denver Health Medical Center underwent VExUS examination before their procedure. VExUS grades were assigned before RHC, blinding ultrasonographers to RHC outcomes. After controlling for age, sex, and common comorbidities, we observed a significant positive association between RAP and VExUS grade (P < 0.001, R2 = .68). VExUS had a favorable AUC for prediction of a RAP ≥ 12 mmHg (0.99, 95% CI 0.96-1) compared to IVC diameter (0.79, 95% CI 0.65-0.92). These results suggest a strong correlation between VExUS and RAP in a diverse patient population, and support future studies of VExUS as a tool to assess venous congestion and guide management in a spectrum of critical illnesses.
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Affiliation(s)
- August Longino
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO, USA.
| | - Katharine Martin
- School of Medicine, University of Colorado, University of Colorado, Aurora, CO, USA
| | - Katarina Leyba
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Gabriel Siegel
- Department of Emergency Medicine, University of Colorado Hospital, Aurora, CO, USA
| | - Edward Gill
- Department of Cardiology, University of Colorado, Aurora, CO, USA
| | - Ivor S Douglas
- Department of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Joseph Burke
- Department of Cardiology, Denver Health Medical Center, Denver, CO, USA
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Self WH, Shotwell MS, Gibbs KW, de Wit M, Files DC, Harkins M, Hudock KM, Merck LH, Moskowitz A, Apodaca KD, Barksdale A, Safdar B, Javaheri A, Sturek JM, Schrager H, Iovine N, Tiffany B, Douglas IS, Levitt J, Busse LW, Ginde AA, Brown SM, Hager DN, Boyle K, Duggal A, Khan A, Lanspa M, Chen P, Puskarich M, Vonderhaar D, Venkateshaiah L, Gentile N, Rosenberg Y, Troendle J, Bistran-Hall AJ, DeClercq J, Lavieri R, Joly MM, Orr M, Pulley J, Rice TW, Schildcrout JS, Semler MW, Wang L, Bernard GR, Collins SP. Renin-Angiotensin System Modulation With Synthetic Angiotensin (1-7) and Angiotensin II Type 1 Receptor-Biased Ligand in Adults With COVID-19: Two Randomized Clinical Trials. JAMA 2023; 329:1170-1182. [PMID: 37039791 PMCID: PMC10091180 DOI: 10.1001/jama.2023.3546] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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] [Received: 12/21/2022] [Accepted: 02/24/2023] [Indexed: 04/12/2023]
Abstract
Importance Preclinical models suggest dysregulation of the renin-angiotensin system (RAS) caused by SARS-CoV-2 infection may increase the relative activity of angiotensin II compared with angiotensin (1-7) and may be an important contributor to COVID-19 pathophysiology. Objective To evaluate the efficacy and safety of RAS modulation using 2 investigational RAS agents, TXA-127 (synthetic angiotensin [1-7]) and TRV-027 (an angiotensin II type 1 receptor-biased ligand), that are hypothesized to potentiate the action of angiotensin (1-7) and mitigate the action of the angiotensin II. Design, Setting, and Participants Two randomized clinical trials including adults hospitalized with acute COVID-19 and new-onset hypoxemia were conducted at 35 sites in the US between July 22, 2021, and April 20, 2022; last follow-up visit: July 26, 2022. Interventions A 0.5-mg/kg intravenous infusion of TXA-127 once daily for 5 days or placebo. A 12-mg/h continuous intravenous infusion of TRV-027 for 5 days or placebo. Main Outcomes and Measures The primary outcome was oxygen-free days, an ordinal outcome that classifies a patient's status at day 28 based on mortality and duration of supplemental oxygen use; an adjusted odds ratio (OR) greater than 1.0 indicated superiority of the RAS agent vs placebo. A key secondary outcome was 28-day all-cause mortality. Safety outcomes included allergic reaction, new kidney replacement therapy, and hypotension. Results Both trials met prespecified early stopping criteria for a low probability of efficacy. Of 343 patients in the TXA-127 trial (226 [65.9%] aged 31-64 years, 200 [58.3%] men, 225 [65.6%] White, and 274 [79.9%] not Hispanic), 170 received TXA-127 and 173 received placebo. Of 290 patients in the TRV-027 trial (199 [68.6%] aged 31-64 years, 168 [57.9%] men, 195 [67.2%] White, and 225 [77.6%] not Hispanic), 145 received TRV-027 and 145 received placebo. Compared with placebo, both TXA-127 (unadjusted mean difference, -2.3 [95% CrI, -4.8 to 0.2]; adjusted OR, 0.88 [95% CrI, 0.59 to 1.30]) and TRV-027 (unadjusted mean difference, -2.4 [95% CrI, -5.1 to 0.3]; adjusted OR, 0.74 [95% CrI, 0.48 to 1.13]) resulted in no difference in oxygen-free days. In the TXA-127 trial, 28-day all-cause mortality occurred in 22 of 163 patients (13.5%) in the TXA-127 group vs 22 of 166 patients (13.3%) in the placebo group (adjusted OR, 0.83 [95% CrI, 0.41 to 1.66]). In the TRV-027 trial, 28-day all-cause mortality occurred in 29 of 141 patients (20.6%) in the TRV-027 group vs 18 of 140 patients (12.9%) in the placebo group (adjusted OR, 1.52 [95% CrI, 0.75 to 3.08]). The frequency of the safety outcomes was similar with either TXA-127 or TRV-027 vs placebo. Conclusions and Relevance In adults with severe COVID-19, RAS modulation (TXA-127 or TRV-027) did not improve oxygen-free days vs placebo. These results do not support the hypotheses that pharmacological interventions that selectively block the angiotensin II type 1 receptor or increase angiotensin (1-7) improve outcomes for patients with severe COVID-19. Trial Registration ClinicalTrials.gov Identifier: NCT04924660.
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Affiliation(s)
- Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin W. Gibbs
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Marjolein de Wit
- Department of Medicine, Virginia Commonwealth University, Richmond
| | - D. Clark Files
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Michelle Harkins
- Department of Internal Medicine, University of New Mexico, Albuquerque
| | | | - Lisa H. Merck
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond
| | - Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | | | - Aaron Barksdale
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Ali Javaheri
- Department of Medicine, Washington University, St Louis, Missouri
| | | | - Harry Schrager
- Department of Medicine, Tufts School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Nicole Iovine
- Department of Medicine, University of Florida, Gainesville
| | | | - Ivor S. Douglas
- Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Joseph Levitt
- Department of Medicine, Stanford University, Stanford, California
| | | | - Adit A. Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora
| | - Samuel M. Brown
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - David N. Hager
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Katherine Boyle
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Akram Khan
- Department of Medicine, Oregon Health & Science University, Portland
| | - Michael Lanspa
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis
| | - Derek Vonderhaar
- Department of Medicine, Ochsner Medical Center, New Orleans, Louisiana
| | | | - Nina Gentile
- Department of Emergency Medicine, Temple University, Philadelphia, Pennsylvania
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - James Troendle
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Amanda J. Bistran-Hall
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Lavieri
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghan Morrison Joly
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Orr
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Matthew W. Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sean P. Collins
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville
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Shapiro NI, Douglas IS, Brower RG, Brown SM, Exline MC, Ginde AA, Gong MN, Grissom CK, Hayden D, Hough CL, Huang W, Iwashyna TJ, Jones AE, Khan A, Lai P, Liu KD, Miller CD, Oldmixon K, Park PK, Rice TW, Ringwood N, Semler MW, Steingrub JS, Talmor D, Thompson BT, Yealy DM, Self WH. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med 2023; 388:499-510. [PMID: 36688507 PMCID: PMC10685906 DOI: 10.1056/nejmoa2212663] [Citation(s) in RCA: 74] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intravenous fluids and vasopressor agents are commonly used in early resuscitation of patients with sepsis, but comparative data for prioritizing their delivery are limited. METHODS In an unblinded superiority trial conducted at 60 U.S. centers, we randomly assigned patients to either a restrictive fluid strategy (prioritizing vasopressors and lower intravenous fluid volumes) or a liberal fluid strategy (prioritizing higher volumes of intravenous fluids before vasopressor use) for a 24-hour period. Randomization occurred within 4 hours after a patient met the criteria for sepsis-induced hypotension refractory to initial treatment with 1 to 3 liters of intravenous fluid. We hypothesized that all-cause mortality before discharge home by day 90 (primary outcome) would be lower with a restrictive fluid strategy than with a liberal fluid strategy. Safety was also assessed. RESULTS A total of 1563 patients were enrolled, with 782 assigned to the restrictive fluid group and 781 to the liberal fluid group. Resuscitation therapies that were administered during the 24-hour protocol period differed between the two groups; less intravenous fluid was administered in the restrictive fluid group than in the liberal fluid group (difference of medians, -2134 ml; 95% confidence interval [CI], -2318 to -1949), whereas the restrictive fluid group had earlier, more prevalent, and longer duration of vasopressor use. Death from any cause before discharge home by day 90 occurred in 109 patients (14.0%) in the restrictive fluid group and in 116 patients (14.9%) in the liberal fluid group (estimated difference, -0.9 percentage points; 95% CI, -4.4 to 2.6; P = 0.61); 5 patients in the restrictive fluid group and 4 patients in the liberal fluid group had their data censored (lost to follow-up). The number of reported serious adverse events was similar in the two groups. CONCLUSIONS Among patients with sepsis-induced hypotension, the restrictive fluid strategy that was used in this trial did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy. (Funded by the National Heart, Lung, and Blood Institute; CLOVERS ClinicalTrials.gov number, NCT03434028.).
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Affiliation(s)
- Nathan I Shapiro
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Ivor S Douglas
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Roy G Brower
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Samuel M Brown
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Matthew C Exline
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Adit A Ginde
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Michelle N Gong
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Colin K Grissom
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Douglas Hayden
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Catherine L Hough
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Weixing Huang
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Theodore J Iwashyna
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Alan E Jones
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Akram Khan
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Poying Lai
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Kathleen D Liu
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Chadwick D Miller
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Katherine Oldmixon
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Pauline K Park
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Todd W Rice
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Nancy Ringwood
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Matthew W Semler
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Jay S Steingrub
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Daniel Talmor
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - B Taylor Thompson
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Donald M Yealy
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
| | - Wesley H Self
- From the Department of Emergency Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School (N.I.S.), the Biostatistics Center (D.H., W.H., P.L.) and the Department of Medicine (K.O., N.R., B.T.T.), Massachusetts General Hospital, and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.), Boston, and the Department of Medicine, Baystate Medical Center, Springfield (J.S.S.) - all in Massachusetts; the Department of Medicine, Denver Health Medical Center, Denver (I.S.D.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.) - both in Colorado; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B., T.J.I.); the Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, and the Department of Medicine, University of Utah, Salt Lake City - both in Utah (S.M.B., C.K.G.); the Ohio State University Wexner Medical Center, Columbus (M.C.E.); the Department of Medicine, Montefiore Medical Center, Bronx, NY (M.N.G.); the Department of Medicine, Oregon Health and Science University, Portland (C.L.H., A.K.); the Department of Emergency Medicine, University of Mississippi Medical Center, Jackson (A.E.J.); the Department of Medicine, University of California, San Francisco, Medical Center, San Francisco (K.D.L.); the Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (C.D.M.); the Department of Surgery, University of Michigan Medical School, Ann Arbor (P.K.P.); the Departments of Medicine (T.W.R., M.W.S.) and Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; and the Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh (D.M.Y.)
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18
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Prekker ME, Driver BE, Trent SA, Resnick-Ault D, Seitz K, Russell DW, Gandotra S, Gaillard JP, Gibbs KW, Latimer A, Whitson MR, Ghamande S, Vonderhaar DJ, Walco JP, Hansen SJ, Douglas IS, Barnes CR, Krishnamoorthy V, Bastman JJ, Lloyd BD, Robison SW, Palakshappa JA, Mitchell S, Page DB, White HD, Espinera A, Hughes C, Joffe AM, Herbert JT, Schauer SG, Long BJ, Imhoff B, Wang L, Rhoads JP, Womack KN, Janz D, Self WH, Rice TW, Ginde AA, Casey JD, Semler MW. DirEct versus VIdeo LaryngosCopE (DEVICE): protocol and statistical analysis plan for a randomised clinical trial in critically ill adults undergoing emergency tracheal intubation. BMJ Open 2023; 13:e068978. [PMID: 36639210 PMCID: PMC9843219 DOI: 10.1136/bmjopen-2022-068978] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Among critically ill patients undergoing orotracheal intubation in the emergency department (ED) or intensive care unit (ICU), failure to visualise the vocal cords and intubate the trachea on the first attempt is associated with an increased risk of complications. Two types of laryngoscopes are commonly available: direct laryngoscopes and video laryngoscopes. For critically ill adults undergoing emergency tracheal intubation, it remains uncertain whether the use of a video laryngoscope increases the incidence of successful intubation on the first attempt compared with the use of a direct laryngoscope. METHODS AND ANALYSIS The DirEct versus VIdeo LaryngosCopE (DEVICE) trial is a prospective, multicentre, non-blinded, randomised trial being conducted in 7 EDs and 10 ICUs in the USA. The trial plans to enrol up to 2000 critically ill adults undergoing orotracheal intubation with a laryngoscope. Eligible patients are randomised 1:1 to the use of a video laryngoscope or a direct laryngoscope for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is the incidence of severe complications between induction and 2 min after intubation, defined as the occurrence of one or more of the following: severe hypoxaemia (lowest oxygen saturation <80%); severe hypotension (systolic blood pressure <65 mm Hg or new or increased vasopressor administration); cardiac arrest or death. Enrolment began on 19 March 2022 and is expected to be completed in 2023. ETHICS AND DISSEMINATION The trial protocol was approved with waiver of informed consent by the single institutional review board at Vanderbilt University Medical Center and the Human Research Protection Office of the Department of Defense. The results will be presented at scientific conferences and submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT05239195).
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Stacy A Trent
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Daniel Resnick-Ault
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Kevin Seitz
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Derek W Russell
- Pulmonary Section, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sheetal Gandotra
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John P Gaillard
- Department of Emergency Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
- Department of Anesthesiology, Section on Critical Care, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Kevin W Gibbs
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Andrew Latimer
- Department of Emergency Medicine, University of Washington Harborview Medical Center, Seattle, Washington, USA
| | - Micah R Whitson
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shekhar Ghamande
- Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Baylor Scott & White Medical Center, Temple, Texas, USA
| | - Derek J Vonderhaar
- Department of Pulmonary and Critical Care Medicine, Ochsner Health, New Orleans, Louisiana, USA
| | - Jeremy P Walco
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sydney J Hansen
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Ivor S Douglas
- Division of Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, Colorado, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Christopher R Barnes
- Department of Anesthesiology and Critical Care Medicine, University of Washington Harborview Medical Center, Seattle, Washington, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jill J Bastman
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Bradley Daniel Lloyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah W Robison
- Pulmonary Section, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jessica A Palakshappa
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Steven Mitchell
- Department of Emergency Medicine, University of Washington Harborview Medical Center, Seattle, Washington, USA
| | - David B Page
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Heath D White
- Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Baylor Scott & White Medical Center, Temple, Texas, USA
| | - Alyssa Espinera
- Department of Pulmonary and Critical Care Medicine, Ochsner Health, New Orleans, Louisiana, USA
| | - Christopher Hughes
- Department of Anesthesiology, Division of Anesthesia Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aaron M Joffe
- Department of Anesthesiology and Critical Care Medicine, University of Washington Harborview Medical Center, Seattle, Washington, USA
| | - J Taylor Herbert
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Brit J Long
- 59th Medical Wing, Joint Base San Antonio-Lackland, Texas, USA
| | - Brant Imhoff
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jillian P Rhoads
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelsey N Womack
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David Janz
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, University Medical Center New Orleans, New Orleans, Louisiana, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Jonathan D Casey
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew W Semler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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19
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Mehta AB, Lockhart S, Reed K, Griesmer C, Glasgow RE, Moss M, Douglas IS, Morris MA. Drivers of Burnout Among Critical Care Providers: A Multicenter Mixed-Methods Study. Chest 2022; 161:1263-1274. [PMID: 34896094 PMCID: PMC9131031 DOI: 10.1016/j.chest.2021.11.034] [Citation(s) in RCA: 18] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/11/2021] [Accepted: 11/28/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Critical care practitioners have some of the highest levels of burnout in health care. RESEARCH QUESTION What are key drivers of burnout across the multidisciplinary ICU team? STUDY DESIGN AND METHODS We conducted a multicenter mixed-methods cohort study in ICUs at three diverse hospitals. We recruited physicians, nurses, respiratory therapists, and other staff members who worked primarily in an ICU. Participants completed the Maslach Burnout Inventory for Human Services Survey for Medical Personnel (MBI) and a qualitative focus group or interview using a phenomenologic approach. MBI subscales for emotional exhaustion, depersonalization, and lack of personal accomplishment were calculated. Emergent shared themes contributing to burnout were identified from qualitative interviews. RESULTS Fifty-eight providers (26 physicians, 22 nurses, six respiratory therapists, three pharmacists, and one case manager) participated. Ten participants (17.9%) described their burnout as moderate to high. However, participants scored moderate or high levels across the three MBI subscales (emotional exhaustion, 71.4%; depersonalization, 53.6%; and lack of personal achievement, 53.6%). Drivers of burnout aligned with three core themes: patient factors, team dynamics, and hospital culture. Individual drivers included medically futile cases, difficult families, contagiousness of burnout, lack of respect between team members, the increasing burden of administrative or regulatory requirements at the cost of time with patients, lack of recognition from hospital leadership, and technology. All were highly interconnected across the three larger domains. Despite differences in MBI scores, most provider types described very similar drivers of burnout. INTERPRETATION High levels of burnout were identified through the MBI, but participants did not self-report high levels of burnout, suggesting a lack of awareness. Drivers of burnout were highly interconnected, but factors related to team dynamics and hospital culture were most prominent and shared across provider types. The shared drivers of burnout across multiple provider types highlights the need for interventions focused on team- and system-level drivers.
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Affiliation(s)
- Anuj B Mehta
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Denver Health & Hospital Association, Denver, CO; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Steven Lockhart
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kathryne Reed
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Denver Health & Hospital Association, Denver, CO
| | - Christine Griesmer
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
| | - Russell E Glasgow
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ivor S Douglas
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Denver Health & Hospital Association, Denver, CO; Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Megan A Morris
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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20
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Rosas IO, Bräu N, Waters M, Go RC, Malhotra A, Hunter BD, Bhagani S, Skiest D, Savic S, Douglas IS, Garcia-Diaz J, Aziz MS, Cooper N, Youngstein T, Sorbo LD, Zerda DJDL, Ustianowski A, Gracian AC, Blyth KG, Carratalà J, François B, Benfield T, Haslem D, Bonfanti P, van der Leest CH, Rohatgi N, Wiese L, Luyt CE, Bauer RN, Cai F, Lee IT, Matharu B, Metcalf L, Wildum S, Graham E, Tsai L, Bao M. Tocilizumab in patients hospitalised with COVID-19 pneumonia: Efficacy, safety, viral clearance, and antibody response from a randomised controlled trial (COVACTA). EClinicalMedicine 2022; 47:101409. [PMID: 35475258 PMCID: PMC9022847 DOI: 10.1016/j.eclinm.2022.101409] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In COVACTA, a randomised, placebo-controlled trial in patients hospitalised with coronavirus disease-19 (COVID-19), tocilizumab did not improve 28-day mortality, but shortened hospital and intensive care unit stay. Longer-term effects of tocilizumab in patients with COVID-19 are unknown. Therefore, the efficacy and safety of tocilizumab in COVID-19 beyond day 28 and its impact on Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) clearance and antibody response in COVACTA were investigated. METHODS Adults in Europe and North America hospitalised with COVID-19 (N = 452) between April 3, 2020 and May 28, 2020 were randomly assigned (2:1) to double-blind intravenous tocilizumab or placebo and assessed for efficacy and safety through day 60. Assessments included mortality, time to hospital discharge, SARS-CoV-2 viral load in nasopharyngeal swab and serum samples, and neutralising anti-SARS-CoV-2 antibodies in serum. ClinicalTrials.gov registration: NCT04320615. FINDINGS By day 60, 24·5% (72/294) of patients in the tocilizumab arm and 25·0% (36/144) in the placebo arm died (weighted difference -0·5% [95% CI -9·1 to 8·0]), and 67·0% (197/294) in the tocilizumab arm and 63·9% (92/144) in the placebo arm were discharged from the hospital. Serious infections occurred in 24·1% (71/295) of patients in the tocilizumab arm and 29·4% (42/143) in the placebo arm. Median time to negative reverse transcriptase-quantitative polymerase chain reaction result in nasopharyngeal/oropharyngeal samples was 15·0 days (95% CI 14·0 to 21·0) in the tocilizumab arm and 21·0 days (95% CI 14·0 to 28·0) in the placebo arm. All tested patients had positive test results for neutralising anti-SARS-CoV-2 antibodies at day 60. INTERPRETATION There was no mortality benefit with tocilizumab through day 60. Tocilizumab did not impair viral clearance or host immune response, and no new safety signals were observed. Future investigations may explore potential biomarkers to optimize patient selection for tocilizumab treatment and combination therapy with other treatments. FUNDING F. Hoffmann-La Roche Ltd and the US Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response, Biomedical Advanced Research and Development Authority, under OT number HHSO100201800036C.
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Affiliation(s)
- Ivan O. Rosas
- Pulmonary, Critical Care, and Sleep Medicine, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
- Corresponding author.
| | - Norbert Bräu
- James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Ronaldo C. Go
- Hackensack Meridian School of Medicine and Hackensack University Medical Center, Hackensack, NJ, USA
| | - Atul Malhotra
- University of California San Diego, La Jolla, CA, USA
| | | | | | - Daniel Skiest
- University of Massachusetts Medical School–Baystate, Springfield, MA, USA
| | - Sinisa Savic
- Leeds Teaching Hospitals NHS Trust and National Institute for Health Research–Leeds, Biomedical Research Centre, Leeds, UK
| | - Ivor S. Douglas
- Denver Health Medical Center, Denver, and University of Colorado, Anschutz School of Medicine, Aurora, CO, USA
| | | | | | | | | | | | | | | | - Antonio Cubillo Gracian
- Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal, and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid, Spain
| | - Kevin G. Blyth
- Institute of Cancer Sciences, University of Glasgow/Department of Respiratory Medicine, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jordi Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, Bellvitge Biomedical Research Institute, University of Barcelona, and CIBERINFEC, Barcelona, Spain
| | - Bruno François
- Intensive Care Unit and Inserm CIC1435 and UMR1092, CHU Limoges, Limoges, France
| | - Thomas Benfield
- Center of Research and Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital–Amager and Hvidovre, Hvidovre, Denmark
| | | | - Paolo Bonfanti
- University of Milano–Bicocca and Azienda Ospedaliera San Gerardo di Monza, Monza, Italy
| | | | - Nidhi Rohatgi
- Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lothar Wiese
- Department of Infectious Diseases, Zealand University Hospital, Roskilde, Denmark
| | | | | | - Fang Cai
- Genentech, South San Francisco, CA, USA
| | | | | | | | | | | | | | - Min Bao
- Genentech, South San Francisco, CA, USA
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21
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Gardiner E, Baumgart A, Tong A, Elliott JH, Azevedo LC, Bersten A, Cervantes L, Chew DP, Cho Y, Crowe S, Douglas IS, Evangelidis N, Flemyng E, Horby P, Howell M, Lee J, Lorca E, Lynch D, Marshall JC, Gonzalez AM, McKenzie A, Manera K, Mehta S, Mer M, Morris AC, Nseir S, Povoa P, Reid M, Sakr Y, Shen N, Smyth AR, Snelling T, Strippoli GFM, Teixeira-Pinto A, Torres A, Viecelli AK, Webb S, Williamson PR, Woc-Colburn L, Zhang J, Craig JC. Perspectives of patients, family members, health professionals and the public on the impact of COVID-19 on mental health. J Ment Health 2022; 31:524-533. [PMID: 34983279 DOI: 10.1080/09638237.2021.2022637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The coronavirus (COVID-19) pandemic has seen a global surge in anxiety, depression, post-traumatic stress disorder (PTSD), and stress. AIMS This study aimed to describe the perspectives of patients with COVID-19, their family, health professionals, and the general public on the impact of COVID-19 on mental health. METHODS A secondary thematic analysis was conducted using data from the COVID-19 COS project. We extracted data on the perceived causes and impact of COVID-19 on mental health from an international survey and seven online consensus workshops. RESULTS We identified four themes (with subthemes in parenthesis): anxiety amidst uncertainty (always on high alert, ebb and flow of recovery); anguish of a threatened future (intense frustration of a changed normality, facing loss of livelihood, trauma of ventilation, a troubling prognosis, confronting death); bearing responsibility for transmission (fear of spreading COVID-19 in public; overwhelming guilt of infecting a loved one); and suffering in isolation (severe solitude of quarantine, sick and alone, separation exacerbating grief). CONCLUSION We found that the unpredictability of COVID-19, the fear of long-term health consequences, burden of guilt, and suffering in isolation profoundly impacted mental health. Clinical and public health interventions are needed to manage the psychological consequences arising from this pandemic.
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Affiliation(s)
| | - Amanda Baumgart
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Andrew Bersten
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Lilia Cervantes
- Department of Medicine, Denver Health, Denver, United States
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | | | - Ivor S Douglas
- Department of Medicine, Pulmonary Sciences and Critical Care, School of Medicine Denver, Denver Health and University of Colorado Anschutz, United States
| | - Nicole Evangelidis
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Ella Flemyng
- Editorial and Methods Department, Cochrane, London, UK
| | - Peter Horby
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Eduardo Lorca
- Department of Internal Medicine, Faculty of Medicine, University of Chile, Santiago, Chile
| | | | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Andrea Matus Gonzalez
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | | | - Karine Manera
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Saad Nseir
- Critical Care Centre, CHU Lille, and Lille University, Lille, France
| | - Pedro Povoa
- Nova Medical School, CHRC, Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
| | - Mark Reid
- Department of Medicine, Denver Health, Denver, United States
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing, China
| | - Alan R Smyth
- Evidence Based Child Health Group, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tom Snelling
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Giovanni F M Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Antoni Torres
- Department of Pulmonology, Respiratory Intitute, Hospital Clinic of Barcelona, University of Barcelona (UB), CIBERES, IDIBAPS, Barcelona, Spain
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Steve Webb
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Laila Woc-Colburn
- Department of Infectious Diseases, Emory University Hospital, Atlanta, Georgia, USA
| | - Junhua Zhang
- Evidence-based Medicine center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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22
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Mansoori JN, Clark BJ, Havranek EP, Douglas IS. The Impact of Choice Architecture on Sepsis Fluid Resuscitation Decisions: An Exploratory Survey-Based Study. MDM Policy Pract 2022; 7:23814683221099454. [PMID: 35592271 PMCID: PMC9112319 DOI: 10.1177/23814683221099454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background Discordance with well-known sepsis resuscitation guidelines is often
attributed to rational assessments of patients at the point of care.
Conversely, we sought to explore the impact of choice architecture (i.e.,
the environment, manner, and behavioral psychology within which options are
presented and decisions are made) on decisions to prescribe
guideline-discordant fluid volumes. Design We conducted an electronic, survey-based study using a septic shock clinical
vignette. Physicians from multiple specialties and training levels at an
academic tertiary-care hospital and academic safety-net hospital were
randomized to distinct answer sets: control (6 fluid options), time
constraint (6 fluid options with a 10-s limit to answer), or choice overload
(25 fluid options). The primary outcome was discordance with Surviving
Sepsis Campaign fluid resuscitation guidelines. We also measured response
times and examined the relationship between each choice architecture
intervention group, response time, and guideline discordance. Results A total of 189 of 624 (30.3%) physicians completed the survey. Time spent
answering the vignette was reduced in time constraint (9.5 s, interquartile
range [IQR] 7.3 s to 10.0 s, P < 0.001) and increased in
choice overload (56.8 s, IQR 35.9 s to 86.7 s, P <
0.001) groups compared with control (28.3 s, IQR 20.0 s to 44.6 s). In
contrast, the relative risk of guideline discordance was higher in time
constraint (2.07, 1.33 to 3.23, P = 0.001) and lower in
choice overload (0.75, 0.60, to 0.95, P =0.02) groups.
After controlling for time spent reading the vignette, the overall odds of
choosing guideline-discordant fluid volumes were reduced for every
additional second spent answering the vignette (OR 0.98, 0.97, to 0.99,
P < 0.001). Conclusions Choice architecture may affect fluid resuscitation decisions in sepsis
regardless of patient conditions, warranting further investigation in
real-world contexts. These effects should be considered when implementing
practice guidelines. Highlights
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Affiliation(s)
- Jason N. Mansoori
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Brendan J. Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edward P. Havranek
- Division of Cardiology, Department of Medicine, Denver, CO, USA
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ivor S. Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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23
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Denson JL, Gillet AS, Zu Y, Brown M, Pham T, Yoshida Y, Mauvais-Jarvis F, Douglas IS, Moore M, Tea K, Wetherbie A, Stevens R, Lefante J, Shaffer JG, Armaignac DL, Belden KA, Kaufman M, Heavner SF, Danesh VC, Cheruku SR, St Hill CA, Boman K, Deo N, Bansal V, Kumar VK, Walkey AJ, Kashyap R. Metabolic Syndrome and Acute Respiratory Distress Syndrome in Hospitalized Patients With COVID-19. JAMA Netw Open 2021; 4:e2140568. [PMID: 34935924 PMCID: PMC8696573 DOI: 10.1001/jamanetworkopen.2021.40568] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Obesity, diabetes, and hypertension are common comorbidities in patients with severe COVID-19, yet little is known about the risk of acute respiratory distress syndrome (ARDS) or death in patients with COVID-19 and metabolic syndrome. OBJECTIVE To determine whether metabolic syndrome is associated with an increased risk of ARDS and death from COVID-19. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used data from the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study collected from 181 hospitals across 26 countries from February 15, 2020, to February 18, 2021. Outcomes were compared between patients with metabolic syndrome (defined as ≥3 of the following criteria: obesity, prediabetes or diabetes, hypertension, and dyslipidemia) and a control population without metabolic syndrome. Participants included adult patients hospitalized for COVID-19 during the study period who had a completed discharge status. Data were analyzed from February 22 to October 5, 2021. EXPOSURES Exposures were SARS-CoV-2 infection, metabolic syndrome, obesity, prediabetes or diabetes, hypertension, and/or dyslipidemia. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included ARDS, intensive care unit (ICU) admission, need for invasive mechanical ventilation, and length of stay (LOS). RESULTS Among 46 441 patients hospitalized with COVID-19, 29 040 patients (mean [SD] age, 61.2 [17.8] years; 13 059 [45.0%] women and 15713 [54.1%] men; 6797 Black patients [23.4%], 5325 Hispanic patients [18.3%], and 16 507 White patients [57.8%]) met inclusion criteria. A total of 5069 patients (17.5%) with metabolic syndrome were compared with 23 971 control patients (82.5%) without metabolic syndrome. In adjusted analyses, metabolic syndrome was associated with increased risk of ICU admission (adjusted odds ratio [aOR], 1.32 [95% CI, 1.14-1.53]), invasive mechanical ventilation (aOR, 1.45 [95% CI, 1.28-1.65]), ARDS (aOR, 1.36 [95% CI, 1.12-1.66]), and mortality (aOR, 1.19 [95% CI, 1.08-1.31]) and prolonged hospital LOS (median [IQR], 8.0 [4.2-15.8] days vs 6.8 [3.4-13.0] days; P < .001) and ICU LOS (median [IQR], 7.0 [2.8-15.0] days vs 6.4 [2.7-13.0] days; P < .001). Each additional metabolic syndrome criterion was associated with increased risk of ARDS in an additive fashion (1 criterion: 1147 patients with ARDS [10.4%]; P = .83; 2 criteria: 1191 patients with ARDS [15.3%]; P < .001; 3 criteria: 817 patients with ARDS [19.3%]; P < .001; 4 criteria: 203 patients with ARDS [24.3%]; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that metabolic syndrome was associated with increased risks of ARDS and death in patients hospitalized with COVID-19. The association with ARDS was cumulative for each metabolic syndrome criteria present.
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Affiliation(s)
- Joshua L Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Yuanhao Zu
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Margo Brown
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Thaidan Pham
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Yilin Yoshida
- Section of Endocrinology and Metabolism, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
- Southeast Louisiana Veterans Affairs Healthcare System, New Orleans
| | - Franck Mauvais-Jarvis
- Section of Endocrinology and Metabolism, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
- Southeast Louisiana Veterans Affairs Healthcare System, New Orleans
| | - Ivor S Douglas
- Division of Pulmonary Sciences & Critical Care Medicine, Denver Health Medical Center, Denver, Colorado
- University of Colorado, Anschutz School of Medicine, Aurora
| | - Mathew Moore
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Kevin Tea
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Andrew Wetherbie
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Rachael Stevens
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - John Lefante
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Jeffrey G Shaffer
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | | | - Katherine A Belden
- Division of Infectious Diseases, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Smith F Heavner
- Prisma Health Department of Medicine, Prisma Health Upstate, Greenville, South Carolina
| | - Valerie C Danesh
- Baylor Scott & White Health, Department of Nursing, Dallas, Texas
| | - Sreekanth R Cheruku
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, Texas
| | | | - Karen Boman
- Society of Critical Care Medicine, Mount Prospect, Illinois
| | - Neha Deo
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vikas Bansal
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Allan J Walkey
- The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care; Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Rahul Kashyap
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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24
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Affiliation(s)
- Jason Haukoos
- Department of Emergency Medicine, Denver Health and the University of Colorado School of Medicine, Denver
- Department of Epidemiology, Colorado School of Public Health, Aurora
| | - Ivor S Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, Denver Health and the University of Colorado School of Medicine, Denver
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25
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Steel TL, Afshar M, Edwards S, Jolley SE, Timko C, Clark BJ, Douglas IS, Dzierba AL, Gershengorn HB, Gilpin NW, Godwin DW, Hough CL, Maldonado JR, Mehta AB, Nelson LS, Patel MB, Rastegar DA, Stollings JL, Tabakoff B, Tate JA, Wong A, Burnham EL. Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:e61-e87. [PMID: 34609257 PMCID: PMC8528516 DOI: 10.1164/rccm.202108-1845st] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.
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26
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Rosas IO, Bräu N, Waters M, Go RC, Hunter BD, Bhagani S, Skiest D, Aziz MS, Cooper N, Douglas IS, Savic S, Youngstein T, Del Sorbo L, Cubillo Gracian A, De La Zerda DJ, Ustianowski A, Bao M, Dimonaco S, Graham E, Matharu B, Spotswood H, Tsai L, Malhotra A. Tocilizumab in Hospitalized Patients with Severe Covid-19 Pneumonia. N Engl J Med 2021; 384:1503-1516. [PMID: 33631066 PMCID: PMC7953459 DOI: 10.1056/nejmoa2028700] [Citation(s) in RCA: 637] [Impact Index Per Article: 212.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (Covid-19) is associated with immune dysregulation and hyperinflammation, including elevated interleukin-6 levels. The use of tocilizumab, a monoclonal antibody against the interleukin-6 receptor, has resulted in better outcomes in patients with severe Covid-19 pneumonia in case reports and retrospective observational cohort studies. Data are needed from randomized, placebo-controlled trials. METHODS In this phase 3 trial, we randomly assigned patients who were hospitalized with severe Covid-19 pneumonia in a 2:1 ratio receive a single intravenous infusion of tocilizumab (at a dose of 8 mg per kilogram of body weight) or placebo. Approximately one quarter of the participants received a second dose of tocilizumab or placebo 8 to 24 hours after the first dose. The primary outcome was clinical status at day 28 on an ordinal scale ranging from 1 (discharged or ready for discharge) to 7 (death) in the modified intention-to-treat population, which included all the patients who had received at least one dose of tocilizumab or placebo. RESULTS Of the 452 patients who underwent randomization, 438 (294 in the tocilizumab group and 144 in the placebo group) were included in the primary and secondary analyses. The median value for clinical status on the ordinal scale at day 28 was 1.0 (95% confidence interval [CI], 1.0 to 1.0) in the tocilizumab group and 2.0 (non-ICU hospitalization without supplemental oxygen) (95% CI, 1.0 to 4.0) in the placebo group (between-group difference, -1.0; 95% CI, -2.5 to 0; P = 0.31 by the van Elteren test). In the safety population, serious adverse events occurred in 103 of 295 patients (34.9%) in the tocilizumab group and in 55 of 143 patients (38.5%) in the placebo group. Mortality at day 28 was 19.7% in the tocilizumab group and 19.4% in the placebo group (weighted difference, 0.3 percentage points; 95% CI, -7.6 to 8.2; nominal P = 0.94). CONCLUSIONS In this randomized trial involving hospitalized patients with severe Covid-19 pneumonia, the use of tocilizumab did not result in significantly better clinical status or lower mortality than placebo at 28 days. (Funded by F. Hoffmann-La Roche and the Department of Health and Human Services; COVACTA ClinicalTrials.gov number, NCT04320615.).
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Affiliation(s)
- Ivan O Rosas
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Norbert Bräu
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Michael Waters
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Ronaldo C Go
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Bradley D Hunter
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Sanjay Bhagani
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Daniel Skiest
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Mariam S Aziz
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Nichola Cooper
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Ivor S Douglas
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Sinisa Savic
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Taryn Youngstein
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Lorenzo Del Sorbo
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Antonio Cubillo Gracian
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - David J De La Zerda
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Andrew Ustianowski
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Min Bao
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Sophie Dimonaco
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Emily Graham
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Balpreet Matharu
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Helen Spotswood
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Larry Tsai
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
| | - Atul Malhotra
- From Baylor College of Medicine, Houston (I.O.R.); James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York - both in New York (N.B.); eStudy Site, Chula Vista (M.W.), Genentech, South San Francisco (M.B., L.T.), and the University of California, San Diego, La Jolla (A.M.) - all in California; Hackensack Meridian School of Medicine and Hacksensack University Medical Center, Hackensack, NJ (R.C.G.); Intermountain Healthcare, Salt Lake City (B.D.H.); Royal Free Hospital (S.B.) and Imperial College London (N.C., T.Y.), London, Leeds Teaching Hospitals NHS Trust and National Institute for Health Research-Leeds Biomedical Research Centre, Leeds (S.S.), North Manchester General Hospital, Manchester (A.U.), and Roche Products, Welwyn Garden City (S.D., E.G., B.M., H.S.) - all in the United Kingdom; the University of Massachusetts Medical School-Baystate, Springfield (D.S.); Rush University Medical Center, Chicago (M.S.A.); Denver Health Medical Center, Denver (I.S.D.), and the University of Colorado, Anschutz School of Medicine, Aurora (I.S.D.); University Health Network, Toronto (L.D.S.); Hospital Universitario HM Sanchinarro, Centro Integral, Oncológico Clara Campal and Departamento de Ciencias Médicas Clínicas, Facultad de Medicina, Universidad CEU San Pablo, Madrid (A.C.G.); and the University of Miami Miller School of Medicine, Miami (D.J.D.L.Z.)
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Sanchez JM, Farasat M, Levy AE, Douglas IS, Stauffer BL, Tzou WS, West JJ. A novel approach to electrocardiography in the prone patient. Heart Rhythm O2 2020; 2:107-109. [PMID: 34113910 PMCID: PMC8183863 DOI: 10.1016/j.hroo.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- José M. Sanchez
- Section of Cardiac Electrophysiology, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
- Address reprint requests and correspondence: Dr José M. Sanchez, 777 Bannock St, MC0960, Denver, CO 80209.
| | - Morteza Farasat
- Division of Cardiology, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Andrew E. Levy
- Division of Cardiology, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Ivor S. Douglas
- Division of Pulmonary & Critical Care, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Brian L. Stauffer
- Division of Cardiology, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - Wendy S. Tzou
- Section of Cardiac Electrophysiology, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
| | - J. Jason West
- Section of Cardiac Electrophysiology, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver, Colorado
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Evangelidis N, Tong A, Howell M, Teixeira-Pinto A, Elliott JH, Azevedo LC, Bersten A, Cervantes L, Chew DP, Crowe S, Douglas IS, Flemyng E, Horby P, Lee J, Lorca E, Lynch D, Marshall JC, McKenzie A, Mehta S, Mer M, Morris AC, Nseir S, Povoa P, Reid M, Sakr Y, Shen N, Smyth AR, Snelling T, Strippoli GFM, Torres A, Turner T, Webb S, Williamson PR, Woc-Colburn L, Zhang J, Baumgart A, Cabrera S, Cho Y, Cooper T, Guha C, Liu E, Gonzalez AM, McLeod C, Natale P, Saglimbene V, Viecelli AK, Craig JC. International Survey to Establish Prioritized Outcomes for Trials in People With Coronavirus Disease 2019. Crit Care Med 2020; 48:1612-1621. [PMID: 32804789 PMCID: PMC7448718 DOI: 10.1097/ccm.0000000000004584] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES There are over 4,000 trials conducted in people with coronavirus disease 2019. However, the variability of outcomes and the omission of patient-centered outcomes may diminish the impact of these trials on decision-making. The aim of this study was to generate a consensus-based, prioritized list of outcomes for coronavirus disease 2019 trials. DESIGN In an online survey conducted in English, Chinese, Italian, Portuguese, and Spanish languages, adults with coronavirus disease 2019, their family members, health professionals, and the general public rated the importance of outcomes using a 9-point Likert scale (7-9, critical importance) and completed a Best-Worst Scale to estimate relative importance. Participant comments were analyzed thematically. SETTING International. SUBJECTS Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public, and health professionals (including clinicians, policy makers, regulators, funders, and researchers). INTERVENTIONS None. MEASUREMENTS None. MAIN RESULTS In total, 9,289 participants from 111 countries (776 people with coronavirus disease 2019 or family members, 4,882 health professionals, and 3,631 members of the public) completed the survey. The four outcomes of highest priority for all three groups were: mortality, respiratory failure, pneumonia, and organ failure. Lung function, lung scarring, sepsis, shortness of breath, and oxygen level in the blood were common to the top 10 outcomes across all three groups (mean > 7.5, median ≥ 8, and > 70% of respondents rated the outcome as critically important). Patients/family members rated fatigue, anxiety, chest pain, muscle pain, gastrointestinal problems, and cardiovascular disease higher than health professionals. Four themes underpinned prioritization: fear of life-threatening, debilitating, and permanent consequences; addressing knowledge gaps; enabling preparedness and planning; and tolerable or infrequent outcomes. CONCLUSIONS Life-threatening respiratory and other organ outcomes were consistently highly prioritized by all stakeholder groups. Patients/family members gave higher priority to many patient-reported outcomes compared with health professionals.
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Affiliation(s)
- Nicole Evangelidis
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Andrew Bersten
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | | | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | | | - Ivor S Douglas
- Department of Medicine, Pulmonary Sciences and Critical Care, Denver Health and University of Colorado Anschutz, School of Medicine, Denver, CO
| | - Ella Flemyng
- Editorial and Methods Department, Cochrane, London, United Kingdom
| | - Peter Horby
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Eduardo Lorca
- Department of Internal Medicine, Faculty of Medicine, University of Chile, Santiago, Chile
| | | | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mervyn Mer
- Divisions of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Saad Nseir
- Critical Care Centre, CHU Lille, and Lille University, F-59000 Lille, France
| | - Pedro Povoa
- Nova Medical School, CHRC, New University of Lisbon, Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal. Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
| | - Mark Reid
- Department of Medicine, Denver Health, Denver, CO
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing, China
| | - Alan R Smyth
- Evidence Based Child Health Group, University of Nottingham, Nottingham, United Kingdom
| | - Tom Snelling
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Giovanni F M Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Antoni Torres
- Department of Pulmonology Hospital Clinic. University of Barcelona, CIBERES, IDIBAPS, ICREA, Barcelona, Spain
| | - Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Steve Webb
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paula R Williamson
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Laila Woc-Colburn
- Section of Infectious Diseases Department of Medicine, National School of Tropical Medicine Baylor College of Medicine, Houston, TX
| | - Junhua Zhang
- Evidence-based Medicine center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Amanda Baumgart
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Sebastian Cabrera
- Department of Internal Medicine, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Yeoungjee Cho
- Faculty of Medicine, University of Queensland, Brisbane, Old, Australia
| | - Tess Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Chandana Guha
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Emma Liu
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Andrea Matus Gonzalez
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Charlie McLeod
- Department of Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Valeria Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Andrea K Viecelli
- Faculty of Medicine, University of Queensland, Brisbane, Old, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Tong A, Elliott JH, Azevedo LC, Baumgart A, Bersten A, Cervantes L, Chew DP, Cho Y, Cooper T, Crowe S, Douglas IS, Evangelidis N, Flemyng E, Hannan E, Horby P, Howell M, Lee J, Liu E, Lorca E, Lynch D, Marshall JC, Gonzalez AM, McKenzie A, Manera KE, McLeod C, Mehta S, Mer M, Morris AC, Nseir S, Povoa P, Reid M, Sakr Y, Shen N, Smyth AR, Snelling T, Strippoli GF, Teixeira-Pinto A, Torres A, Turner T, Viecelli AK, Webb S, Williamson PR, Woc-Colburn L, Zhang J, Craig JC. Core Outcomes Set for Trials in People With Coronavirus Disease 2019. Crit Care Med 2020; 48:1622-1635. [PMID: 32804792 PMCID: PMC7448717 DOI: 10.1097/ccm.0000000000004585] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The outcomes reported in trials in coronavirus disease 2019 are extremely heterogeneous and of uncertain patient relevance, limiting their applicability for clinical decision-making. The aim of this workshop was to establish a core outcomes set for trials in people with suspected or confirmed coronavirus disease 2019. DESIGN Four international online multistakeholder consensus workshops were convened to discuss proposed core outcomes for trials in people with suspected or confirmed coronavirus disease 2019, informed by a survey involving 9,289 respondents from 111 countries. The transcripts were analyzed thematically. The workshop recommendations were used to finalize the core outcomes set. SETTING International. SUBJECTS Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public and health professionals (including clinicians, policy makers, regulators, funders, researchers). INTERVENTIONS None. MEASUREMENTS None. MAIN RESULTS Six themes were identified. "Responding to the critical and acute health crisis" reflected the immediate focus on saving lives and preventing life-threatening complications that underpinned the high prioritization of mortality, respiratory failure, and multiple organ failure. "Capturing different settings of care" highlighted the need to minimize the burden on hospitals and to acknowledge outcomes in community settings. "Encompassing the full trajectory and severity of disease" was addressing longer term impacts and the full spectrum of illness (e.g. shortness of breath and recovery). "Distinguishing overlap, correlation and collinearity" meant recognizing that symptoms such as shortness of breath had distinct value and minimizing overlap (e.g. lung function and pneumonia were on the continuum toward respiratory failure). "Recognizing adverse events" refers to the potential harms of new and evolving interventions. "Being cognizant of family and psychosocial wellbeing" reflected the pervasive impacts of coronavirus disease 2019. CONCLUSIONS Mortality, respiratory failure, multiple organ failure, shortness of breath, and recovery are critically important outcomes to be consistently reported in coronavirus disease 2019 trials.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Amanda Baumgart
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Andrew Bersten
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Yeoungjee Cho
- Faculty of Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Tess Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | | | - Ivor S Douglas
- Department of Medicine, Pulmonary Sciences and Critical Care, Denver Health and University of Colorado Anschutz, School of Medicine Denver, Aurora, CO
| | - Nicole Evangelidis
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Ella Flemyng
- Department of Editorial and Methods, Cochrane, London, United Kingdom
| | - Elyssa Hannan
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Peter Horby
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Emma Liu
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Eduardo Lorca
- Department of Internal Medicine, Faculty of Medicine, University of Chile, Santiago, Chile
| | | | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Andrea Matus Gonzalez
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | | | - Karine E Manera
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Charlie McLeod
- Department of Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Saad Nseir
- Critical Care Centre, CHU Lille, and Lille University, F-59000 Lille, France
| | - Pedro Povoa
- Nova Medical School, CHRC, New University of Lisbon, Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Mark Reid
- Department of Medicine, Denver Health, Denver, CO
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing, China
| | - Alan R Smyth
- Evidence Based Child Health Group, University of Nottingham, Nottingham, United Kingdom
| | - Tom Snelling
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Antoni Torres
- Department of Pulmonology Hospital Clinic. University of Barcelona, CIBERES, IDIBAPS, Barcelona, Spain
| | - Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrea K Viecelli
- Faculty of Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Steve Webb
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paula R Williamson
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Laila Woc-Colburn
- Section of Infectious Diseases Department of Medicine, National School of Tropical Medicine, Baylor College of Medicine, Houston, TX
| | - Junhua Zhang
- Evidence-based Medicine center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Douglas IS, Alapat PM, Corl KA, Exline MC, Forni LG, Holder AL, Kaufman DA, Khan A, Levy MM, Martin GS, Sahatjian JA, Seeley E, Self WH, Weingarten JA, Williams M, Hansell DM. Fluid Response Evaluation in Sepsis Hypotension and Shock: A Randomized Clinical Trial. Chest 2020; 158:1431-1445. [PMID: 32353418 PMCID: PMC9490557 DOI: 10.1016/j.chest.2020.04.025] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [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: 02/04/2020] [Revised: 03/16/2020] [Accepted: 04/02/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Fluid and vasopressor management in septic shock remains controversial. In this randomized controlled trial, we evaluated the efficacy of dynamic measures (stroke volume change during passive leg raise) to guide resuscitation and improve patient outcome. RESEARCH QUESTION Will resuscitation that is guided by dynamic assessments of fluid responsiveness in patients with septic shock improve patient outcomes? STUDY DESIGN AND METHODS We conducted a prospective, multicenter, randomized clinical trial at 13 hospitals in the United States and United Kingdom. Patients presented to EDs with sepsis that was associated hypotension and anticipated ICU admission. Intervention arm patients were assessed for fluid responsiveness before clinically driven fluid bolus or increase in vasopressors occurred. The protocol included reassessment and therapy as indicated by the passive leg raise result. The control arm received usual care. The primary clinical outcome was positive fluid balance at 72 hours or ICU discharge, whichever occurred first. RESULTS In modified intent-to-treat analysis that included 83 intervention and 41 usual care eligible patients, fluid balance at 72 hours or ICU discharge was significantly lower (-1.37 L favoring the intervention arm; 0.65 ± 2.85 L intervention arm vs 2.02 ± 3.44 L usual care arm; P = .021. Fewer patients required renal replacement therapy (5.1% vs 17.5%; P = .04) or mechanical ventilation (17.7% vs 34.1%; P = .04) in the intervention arm compared with usual care. In the all-randomized intent-to-treat population (102 intervention, 48 usual care), there were no significant differences in safety signals. INTERPRETATION Physiologically informed fluid and vasopressor resuscitation with the use of the passive leg raise-induced stroke volume change to guide management of septic shock is safe and demonstrated lower net fluid balance and reductions in the risk of renal and respiratory failure. Dynamic assessments to guide fluid administration may improve outcomes for patients with septic shock compared with usual care. CLINICAL TRIAL REGISTRATION NCT02837731.
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Affiliation(s)
- Ivor S Douglas
- Pulmonary Science and Critical Care Medicine, Denver Health Medical Center and University of Colorado, Anschutz Medical Campus, Denver, CO.
| | - Philip M Alapat
- Pulmonary, Critical Care and Sleep Medicine, Ben Taub Hospital, Houston, TX
| | - Keith A Corl
- Pulmonary, Critical Care and Sleep Medicine, Rhode Island Hospital, Providence, RI
| | - Matthew C Exline
- Pulmonary, Critical Care and Sleep Medicine, Ohio State University Hospital, Columbus, OH
| | - Lui G Forni
- Intensive Care Medicine and Nephrology, University of Surrey & Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Andre L Holder
- Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
| | - David A Kaufman
- NYU School of Medicine, New York, NY; Pulmonary and Critical Care Medicine, Bridgeport Hospital, Bridgeport, CT
| | - Akram Khan
- Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR
| | - Mitchell M Levy
- Pulmonary, Critical Care and Sleep Medicine, Rhode Island Hospital, Providence, RI
| | - Gregory S Martin
- Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
| | | | - Eric Seeley
- Pulmonary, Critical Care Medicine and Allergy, University of California San Francisco, San Francisco, CA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN
| | - Jeremy A Weingarten
- Pulmonary, Critical Care and Sleep Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Mark Williams
- Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Douglas M Hansell
- Cheetah Medical, Wilmington, DE; Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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Mansoori JN, Linde-Zwirble W, Hou PC, Havranek EP, Douglas IS. Variability in usual care fluid resuscitation and risk-adjusted outcomes for mechanically ventilated patients in shock. Crit Care 2020; 24:25. [PMID: 31992351 PMCID: PMC6986034 DOI: 10.1186/s13054-020-2734-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/04/2019] [Accepted: 01/10/2020] [Indexed: 01/20/2023]
Abstract
RATIONALE There remains significant controversy regarding the optimal approach to fluid resuscitation for patients in shock. The magnitude of care variability in shock resuscitation, the confounding effects of disease severity and comorbidity, and the relative impact on sepsis survival are poorly understood. OBJECTIVE To evaluate usual care variability and determine the differential effect of observed and predicted fluid resuscitation volumes on risk-adjusted hospital mortality for mechanically ventilated patients in shock. METHODS We performed a retrospective outcome analysis of mechanically ventilated patients admitted to intensive care units using the 2013 Premier Hospital Database (Premier, Inc.). Observed and predicted hospital mortality were evaluated by observed and predicted day 1 fluid administration, using the difference in predicted and observed outcomes to adjust for disease severity between groups. Both predictive models were validated using a second large administrative database (Truven Health Analytics Inc.). Secondary outcomes included duration of mechanical ventilation, hospital and ICU length of stay, and cost. RESULTS Among 33,831 patients, observed hospital mortality was incrementally higher than predicted for each additional liter of day 1 fluid beginning at 7 L (40.9% vs. 37.2%, p = 0.008). Compared to patients that received expected (± 1.5 L predicted) day 1 fluid volumes, greater-than-expected fluid resuscitation was associated with increased risk-adjusted hospital mortality (52.3% vs. 45.0%, p < 0.0001) among all patients with shock and among a subgroup of shock patients with comorbid conditions predictive of lower fluid volume administration (47.1% vs. 41.5%, p < 0.0001). However, in patients with shock but without such conditions, both greater-than-expected (57.5% vs. 49.2%, p < 0.0001) and less-than-expected (52.1% vs. 49.2%, p = 0.037) day 1 fluid resuscitation were associated with increased risk-adjusted hospital mortality. CONCLUSIONS Highly variable day 1 fluid resuscitation was associated with a non-uniform impact on risk-adjusted hospital mortality among distinct subgroups of mechanically ventilated patients with shock. These findings support closer evaluation of fluid resuscitation strategies that include broadly applied fluid volume targets in the early phase of shock resuscitation.
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Affiliation(s)
- Jason N Mansoori
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Denver Health Medical Center, 601 Broadway, MC 4000, Denver, CO, 80203, USA. .,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, USA.
| | | | - Peter C Hou
- Division of Emergency Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Edward P Havranek
- Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, USA.,Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, USA
| | - Ivor S Douglas
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Denver Health Medical Center, 601 Broadway, MC 4000, Denver, CO, 80203, USA.,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, USA
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Denson JL, Knoeckel J, Kjerengtroen S, Johnson R, McNair B, Thornton O, Douglas IS, Wechsler ME, Burke RE. Improving end-of-rotation transitions of care among ICU patients. BMJ Qual Saf 2019; 29:250-259. [PMID: 31685581 DOI: 10.1136/bmjqs-2019-009867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/16/2019] [Accepted: 10/20/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Hospitalised patients whose inpatient teams rotate off service experience increased mortality related to end-of-rotation care transitions, yet standardised handoff practices are lacking. OBJECTIVE Develop and implement a multidisciplinary patient-centred handoff intervention to improve outcomes for patients who are critically ill during end-of-rotation transitions. DESIGN, SETTING AND PARTICIPANTS Single-centre, controlled pilot study of medical intensive care unit (ICU) patients whose resident team was undergoing end-of-rotation transition at a university hospital from June 2017 to February 2018. INTERVENTION A 4-item intervention was implemented over two study periods. Intervention 1 included: (1) in-person bedside handoff between teams rotating off and on service, (2) handoff checklist, (3) nursing involvement in handoff, and (4) 30 min education session. Intervention 2 included the additional option to conduct bedside handoff via videoconferencing. MAIN OUTCOME MEASURES Implementation was measured by repeated clinician surveys and direct observation. Patient outcomes included length of stay (LOS; ICU and hospital) and mortality (ICU, hospital and 30 days). Clinician perceptions were modelled over time using per cent positive responses in logistic regression. Patient outcomes were compared with matched control 'transition' patients from 1 year prior to implementation of the intervention. RESULTS Among 270 transition patients, 46.3% were female with a mean age of 55.9 years. Mechanical ventilation (64.1%) and in-hospital death (27.6%) rates were prevalent. Despite high implementation rates-handoff participation (93.8%), checklist utilisation (75.0%), videoconferencing (62.5%), nursing involvement (75.0%)-the intervention did not significantly improve LOS or mortality. Multidisciplinary survey data revealed significant improvement in acceptability by nursing staff, while satisfaction significantly declined for resident physicians. CONCLUSIONS In this controlled pilot study, a structured ICU end-of-rotation care transition strategy was feasible to implement with high fidelity. While mortality and LOS were not affected in a pilot study with limited power, the pragmatic strategy of this intervention holds promise for future trials.
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Affiliation(s)
- Joshua Lee Denson
- Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA .,Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Julie Knoeckel
- Medicine, Denver Health Medical Center, Denver, CO, United States.,Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Sara Kjerengtroen
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Rachel Johnson
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | - Bryan McNair
- Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
| | | | - Ivor S Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA.,Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Michael E Wechsler
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA.,Pulmonary and Critical Care Medicine, National Jewish Health, Denver, Colorado, USA
| | - Robert E Burke
- Section of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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Park BH, Shin MH, Douglas IS, Chung KS, Song JH, Kim SY, Kim EY, Jung JY, Kang YA, Chang J, Kim YS, Park MS. Erythropoietin-Producing Hepatoma Receptor Tyrosine Kinase A2 Modulation Associates with Protective Effect of Prone Position in Ventilator-induced Lung Injury. Am J Respir Cell Mol Biol 2019; 58:519-529. [PMID: 29216437 DOI: 10.1165/rcmb.2017-0143oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The erythropoietin-producing hepatoma (Eph) receptor tyrosine kinase A2 (EphA2) and its ligand, ephrinA1, play a pivotal role in inflammation and tissue injury by modulating the epithelial and endothelial barrier integrity. Therefore, EphA2 receptor may be a potential therapeutic target for modulating ventilator-induced lung injury (VILI). To support this hypothesis, here, we analyzed EphA2/ephrinA1 signaling in the process of VILI and determined the role of EphA2/ephrinA1 signaling in the protective mechanism of prone positioning in a VILI model. Wild-type mice were ventilated with high (24 ml/kg; positive end-expiratory pressure, 0 cm; 5 h) tidal volume in a supine or prone position. Anti-EphA2 receptor antibody or IgG was administered to the supine position group. Injury was assessed by analyzing the BAL fluid, lung injury scoring, and transmission electron microscopy. Lung lysates were evaluated using cytokine/chemokine ELISA and Western blotting of EphA2, ephrinA1, PI3Kγ, Akt, NF-κB, and P70S6 kinase. EphA2/ephrinA1 expression was higher in the supine high tidal volume group than in the control group, but it did not increase upon prone positioning or anti-EphA2 receptor antibody treatment. EphA2 antagonism reduced the extent of VILI and downregulated the expression of PI3Kγ, Akt, NF-κB, and P70S6 kinase. These findings demonstrate that EphA2/ephrinA1 signaling is involved in the molecular mechanism of VILI and that modulation of EphA2/ehprinA1 signaling by prone position or EphA2 antagonism may be associated with the lung-protective effect. Our data provide evidence for EphA2/ehprinA1 as a promising therapeutic target for modulating VILI.
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Affiliation(s)
- Byung Hoon Park
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Gyeonggi Provincial Medical Center Paju Hospital, Paju City, Gyeonggi-Do, Republic of Korea
| | - Mi Hwa Shin
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Ivor S Douglas
- 3 Division of Pulmonary Sciences and Critical Care Medicine, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado
| | - Kyung Soo Chung
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Joo Han Song
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Song Yee Kim
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Eun Young Kim
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Ji Ye Jung
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Young Ae Kang
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Joon Chang
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Young Sam Kim
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
| | - Moo Suk Park
- 2 Division of Pulmonology, The Institute of Chest Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; and
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Douglas IS, Bednash JS, Fein DG, Mallampalli RK, Mansoori JN, Gershengorn HB. Update in Critical Care and Acute Respiratory Distress Syndrome 2018. Am J Respir Crit Care Med 2019; 199:1335-1343. [PMID: 30958975 DOI: 10.1164/rccm.201903-0550up] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ivor S Douglas
- 1 Pulmonary, Sleep and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Joseph S Bednash
- 2 Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Rama K Mallampalli
- 4 Department of Medicine, The Ohio State University, Columbus, Ohio; and
| | - Jason N Mansoori
- 1 Pulmonary, Sleep and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Hayley B Gershengorn
- 5 Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida
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Girard TD, Exline MC, Carson SS, Hough CL, Rock P, Gong MN, Douglas IS, Malhotra A, Owens RL, Feinstein DJ, Khan B, Pisani MA, Hyzy RC, Schmidt GA, Schweickert WD, Hite RD, Bowton DL, Masica AL, Thompson JL, Chandrasekhar R, Pun BT, Strength C, Boehm LM, Jackson JC, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Bernard GR, Dittus RS, Ely EW. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med 2018; 379:2506-2516. [PMID: 30346242 PMCID: PMC6364999 DOI: 10.1056/nejmoa1808217] [Citation(s) in RCA: 309] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are conflicting data on the effects of antipsychotic medications on delirium in patients in the intensive care unit (ICU). METHODS In a randomized, double-blind, placebo-controlled trial, we assigned patients with acute respiratory failure or shock and hypoactive or hyperactive delirium to receive intravenous boluses of haloperidol (maximum dose, 20 mg daily), ziprasidone (maximum dose, 40 mg daily), or placebo. The volume and dose of a trial drug or placebo was halved or doubled at 12-hour intervals on the basis of the presence or absence of delirium, as detected with the use of the Confusion Assessment Method for the ICU, and of side effects of the intervention. The primary end point was the number of days alive without delirium or coma during the 14-day intervention period. Secondary end points included 30-day and 90-day survival, time to freedom from mechanical ventilation, and time to ICU and hospital discharge. Safety end points included extrapyramidal symptoms and excessive sedation. RESULTS Written informed consent was obtained from 1183 patients or their authorized representatives. Delirium developed in 566 patients (48%), of whom 89% had hypoactive delirium and 11% had hyperactive delirium. Of the 566 patients, 184 were randomly assigned to receive placebo, 192 to receive haloperidol, and 190 to receive ziprasidone. The median duration of exposure to a trial drug or placebo was 4 days (interquartile range, 3 to 7). The median number of days alive without delirium or coma was 8.5 (95% confidence interval [CI], 5.6 to 9.9) in the placebo group, 7.9 (95% CI, 4.4 to 9.6) in the haloperidol group, and 8.7 (95% CI, 5.9 to 10.0) in the ziprasidone group (P=0.26 for overall effect across trial groups). The use of haloperidol or ziprasidone, as compared with placebo, had no significant effect on the primary end point (odds ratios, 0.88 [95% CI, 0.64 to 1.21] and 1.04 [95% CI, 0.73 to 1.48], respectively). There were no significant between-group differences with respect to the secondary end points or the frequency of extrapyramidal symptoms. CONCLUSIONS The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium. (Funded by the National Institutes of Health and the VA Geriatric Research Education and Clinical Center; MIND-USA ClinicalTrials.gov number, NCT01211522 .).
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Affiliation(s)
- Timothy D Girard
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Matthew C Exline
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Shannon S Carson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Catherine L Hough
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Peter Rock
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Michelle N Gong
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Ivor S Douglas
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Atul Malhotra
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert L Owens
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Daniel J Feinstein
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Babar Khan
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Margaret A Pisani
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert C Hyzy
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Gregory A Schmidt
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - William D Schweickert
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - R Duncan Hite
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - David L Bowton
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Andrew L Masica
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Jennifer L Thompson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Rameela Chandrasekhar
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Brenda T Pun
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Cayce Strength
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Leanne M Boehm
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - James C Jackson
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Pratik P Pandharipande
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Nathan E Brummel
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Christopher G Hughes
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Mayur B Patel
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Joanna L Stollings
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Gordon R Bernard
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - Robert S Dittus
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
| | - E Wesley Ely
- From the Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.); the Pulmonary, Critical Care, and Sleep Medicine Division, Department of Medicine, Ohio State University Wexner Medical Center, Columbus (M.C.E.), and the Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic Foundation, Cleveland (R.D.H.) - both in Ohio; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (S.S.C.), the Section on Critical Care, Department of Anesthesiology, Wake Forest Baptist Health, Winston-Salem (D.L.B.), and Cone Health System, Greensboro (D.J.F.) - all in North Carolina; the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle (C.L.H.); the Department of Anesthesiology, University of Maryland School of Medicine, Baltimore (P.R.); the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York (M.N.G.); the Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver (I.S.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California at San Diego, San Diego (A.M., R.L.O.); the Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis (B.K.); the Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT (M.A.P.); the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor (R.C.H.); the Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Medicine, University of Iowa Hospitals and Clinics, Iowa City (G.A.S.); , and the Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia (W.D.S.); the Center for Clinical Effectiveness, Baylor Scott and White Health, Dallas (A.L.M.); and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center (J.L.T., R.C., B.T.P., C.S., L.M.B., J.C.J., P.P.P., N.E.B., C.G.H., M.B.P., J.L.S., G.R.B., R.S.D., E.W.E.), the Center for Health Services Research (R.C., J.C.J., C.S., N.E.B., R.S.D., E.W.E.), the Center for Quality Aging (N.E.B., E.W.E.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., C.S., N.E.B., G.R.B., E.W.E.), the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Department of Biostatistics (J.L.T., R.C.), the Department of Psychiatry (J.C.J.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (P.P.P., C.G.H.), the Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), and the Department of Pharmaceutical Services (J.L.S.), Vanderbilt University School of Medicine, Vanderbilt University School of Nursing (L.M.B.), and the Anesthesia Service (P.P.P., C.G.H.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education, and Clinical Center Service (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - all in Nashville
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Borg B, Douglas IS, Hull M, Keniston A, Moss M, Clark BJ. Alcohol misuse and outpatient follow-up after hospital discharge: a retrospective cohort study. Addict Sci Clin Pract 2018; 13:24. [PMID: 30514357 PMCID: PMC6278064 DOI: 10.1186/s13722-018-0125-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 11/29/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose Patients with alcohol misuse are less likely to receive preventive health services but more likely to utilize emergency health services. However, the association between alcohol misuse and outpatient follow-up after hospitalization is unknown and may depend on whether a patient experiences a critical illness. We sought to determine whether alcohol misuse was associated with lower rates of outpatient follow-up after hospital discharge and whether the magnitude of this association differed in patients who experienced a critical illness. Materials and methods This was a retrospective cohort study using administrative data from an urban safety net hospital. Patients were included if they were admitted between 2011 and 2015, were between the ages of 18 and 89, resided within the safety net county, were discharged home, and were at moderate to high risk for hospital readmission within the subsequent 30 days. Alcohol misuse was identified using a combination of ICD-9 codes and response to a single screening question. The primary outcome was a combined measure of follow-up with a primary care physician or specialist provider in the 30 days following hospital discharge. Multivariable logistic regression was used to adjust for factors known to be associated with healthcare utilization. Results Overall, 17,575 patients were included in the analysis; 4984 (28%) had alcohol misuse. In the 30 days following hospital discharge, 46% of patients saw any outpatient provider. In an unadjusted analysis, the association between alcohol misuse and attending any outpatient follow-up was dependent on whether patients had a critical illness (p value < 0.0001) with the highest rates of follow-up in survivors of critical illness without alcohol misuse (53%, 95% CI 51%, 55%) followed by patients without alcohol misuse or critical illness (49%; 95% CI 48%, 50%), patients with alcohol misuse without critical illness (38%; 95% CI 36%, 39%), and patients with alcohol misuse and a critical illness (37%; 95% CI 35%, 40%). Adjusting for factors associated with healthcare utilization, these findings were modestly attenuated but unchanged. Conclusions Patients with alcohol misuse who are at moderate to high risk for hospital readmission may benefit from targeted interventions to increase rates of outpatient follow-up after hospital discharge. Electronic supplementary material The online version of this article (10.1186/s13722-018-0125-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bryan Borg
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ivor S Douglas
- Denver Health Medical Center, Denver, CO, USA.,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Box C272, RC2, 9th Floor, 12700 East 19th Avenue, Aurora, CO, 80045, USA
| | | | | | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Box C272, RC2, 9th Floor, 12700 East 19th Avenue, Aurora, CO, 80045, USA
| | - Brendan J Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Box C272, RC2, 9th Floor, 12700 East 19th Avenue, Aurora, CO, 80045, USA. .,Division of Substance Dependence, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Self WH, Semler MW, Bellomo R, Brown SM, deBoisblanc BP, Exline MC, Ginde AA, Grissom CK, Janz DR, Jones AE, Liu KD, Macdonald SPJ, Miller CD, Park PK, Reineck LA, Rice TW, Steingrub JS, Talmor D, Yealy DM, Douglas IS, Shapiro NI. Liberal Versus Restrictive Intravenous Fluid Therapy for Early Septic Shock: Rationale for a Randomized Trial. Ann Emerg Med 2018; 72:457-466. [PMID: 29753517 DOI: 10.1016/j.annemergmed.2018.03.039] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/25/2018] [Accepted: 03/26/2018] [Indexed: 12/29/2022]
Abstract
Prompt intravenous fluid therapy is a fundamental treatment for patients with septic shock. However, the optimal approach for administering intravenous fluid in septic shock resuscitation is unknown. Two competing strategies are emerging: a liberal fluids approach, consisting of a larger volume of initial fluid (50 to 75 mL/kg [4 to 6 L in an 80-kg adult] during the first 6 hours) and later use of vasopressors, versus a restrictive fluids approach, consisting of a smaller volume of initial fluid (≤30 mL/kg [≤2 to 3 L]), with earlier reliance on vasopressor infusions to maintain blood pressure and perfusion. Early fluid therapy may enhance or maintain tissue perfusion by increasing venous return and cardiac output. However, fluid administration may also have deleterious effects by causing edema within vital organs, leading to organ dysfunction and impairment of oxygen delivery. Conversely, a restrictive fluids approach primarily relies on vasopressors to reverse hypotension and maintain perfusion while limiting the administration of fluid. Both strategies have some evidence to support their use but lack robust data to confirm the benefit of one strategy over the other, creating clinical and scientific equipoise. As part of the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Network, we designed a randomized clinical trial to compare the liberal and restrictive fluids strategies, the Crystalloid Liberal or Vasopressor Early Resuscitation in Sepsis trial. The purpose of this article is to review the current literature on approaches to early fluid resuscitation in adults with septic shock and outline the rationale for the upcoming trial.
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Affiliation(s)
- Wesley H Self
- Vanderbilt University Medical Center, Nashville, TN.
| | | | - Rinaldo Bellomo
- University of Melbourne School of Medicine, Victoria, Australia
| | - Samuel M Brown
- Intermountain Medical Center and University of Utah, Murray, UT
| | | | | | - Adit A Ginde
- University of Colorado School of Medicine, Aurora, CO
| | - Colin K Grissom
- Intermountain Medical Center and University of Utah, Murray, UT
| | - David R Janz
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Alan E Jones
- University of Mississippi Medical Center, Jackson, MS
| | - Kathleen D Liu
- University of California San Francisco Medical Center, San Francisco, CA
| | | | | | | | - Lora A Reineck
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN
| | - Jay S Steingrub
- University of Massachusetts Medical School-Baystate, Springfield, MA
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Mehta AB, Douglas IS, Walkey AJ. Evidence-based Utilization of Noninvasive Ventilation and Patient Outcomes. Ann Am Thorac Soc 2017; 14:1667-1673. [PMID: 28541747 PMCID: PMC5711281 DOI: 10.1513/annalsats.201703-208oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 03/09/2017] [Accepted: 05/25/2017] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Strong evidence supports use of noninvasive ventilation (NIV) for patients with respiratory distress from chronic obstructive pulmonary disease and heart failure (strong evidence conditions [SECs]). Despite unclear benefits of NIV for other causes of acute respiratory failure, utilization for conditions with weaker evidence is increasing, despite evidence demonstrating higher mortality for patients who suffer NIV failure (progression from NIV to invasive mechanical ventilation [IMV])) compared with being treated initially with IMV. OBJECTIVES To determine the association of hospital variation in evidence-based utilization of NIV with patient outcomes. METHODS Using the California State Inpatient Database 2011, we identified adult patients who received NIV. Patients were considered to have an SEC for NIV if they had an acute exacerbation of chronic obstructive pulmonary disease or heart failure. We used multivariable hierarchical logistic regression to determine the association between hospital rates of NIV use for SECs and patient risk of NIV failure (need for IMV after NIV). RESULTS Among 22,706 hospitalizations with NIV as the initial ventilatory strategy, 6,820 (30.0%) had SECs. Patients with SECs had lower risk of NIV failure than patients with weak evidence conditions (8.1 vs. 18.2%, P < 0.0001). Regardless of underlying diagnosis, patients admitted to hospitals with greater use of NIV for SECs had lower risk of NIV failure (Quartile 4 vs. Quartile 1 adjusted odds ratio = 0.62; 95% CI = 0.49-0.80). Even patients without an SEC benefited from admission to hospitals that used NIV more often for patients with SECs (Quartile 4 vs. Quartile 1 adjusted odds ratio for NIV failure = 0.68; 95% CI = 0.52-0.88). CONCLUSIONS Most patients who received NIV did not have conditions with strong supporting evidence for its use with wide institutional variation in patient selection for NIV. Surprisingly, we found that all patients, even those without an SEC, benefited from admission to hospitals with greater evidence-based utilization of NIV, suggesting a "hospital effect" that is synergistic with patient selection.
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Affiliation(s)
- Anuj B. Mehta
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
- Division of Pulmonary and Critical Care Medicine, Denver Health, Denver, Colorado
- Division of Pulmonary and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ivor S. Douglas
- Division of Pulmonary and Critical Care Medicine, Denver Health, Denver, Colorado
- Division of Pulmonary and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Allan J. Walkey
- Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; and
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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Fang WF, Douglas IS, Chen YM, Lin CY, Kao HC, Fang YT, Huang CH, Chang YT, Huang KT, Wang YH, Wang CC, Lin MC. Development and validation of immune dysfunction score to predict 28-day mortality of sepsis patients. PLoS One 2017; 12:e0187088. [PMID: 29073262 PMCID: PMC5658156 DOI: 10.1371/journal.pone.0187088] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [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: 05/09/2017] [Accepted: 10/15/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Sepsis-induced immune dysfunction ranging from cytokines storm to immunoparalysis impacts outcomes. Monitoring immune dysfunction enables better risk stratification and mortality prediction and is mandatory before widely application of immunoadjuvant therapies. We aimed to develop and validate a scoring system according to patients' immune dysfunction status for 28-day mortality prediction. METHODS A prospective observational study from a cohort of adult sepsis patients admitted to ICU between August 2013 and June 2016 at Kaohsiung Chang Gung Memorial Hospital in Taiwan. We evaluated immune dysfunction status through measurement of baseline plasma Cytokine levels, Monocyte human leukocyte-DR expression by flow cytometry, and stimulated immune response using post LPS stimulated cytokine elevation ratio. An immune dysfunction score was created for 28-day mortality prediction and was validated. RESULTS A total of 151 patients were enrolled. Data of the first consecutive 106 septic patients comprised the training cohort, and of other 45 patients comprised the validation cohort. Among the 106 patients, 21 died and 85 were still alive on day 28 after ICU admission. (mortality rate, 19.8%). Independent predictive factors revealed via multivariate logistic regression analysis included segmented neutrophil-to-monocyte ratio, granulocyte-colony stimulating factor, interleukin-10, and monocyte human leukocyte antigen-antigen D-related levels, all of which were selected to construct the score, which predicted 28-day mortality with area under the curve of 0.853 and 0.789 in the training and validation cohorts, respectively. CONCLUSIONS The immune dysfunction scoring system developed here included plasma granulocyte-colony stimulating factor level, interleukin-10 level, serum segmented neutrophil-to-monocyte ratio, and monocyte human leukocyte antigen-antigen D-related expression appears valid and reproducible for predicting 28-day mortality.
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Affiliation(s)
- Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- * E-mail: (WFF); (MCL)
| | - Ivor S. Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver and Denver Health Medical Center, Denver, Colorado, United States of America
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
| | - Chiung-Yu Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
| | - Hsu-Ching Kao
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
| | - Ying-Tang Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
| | - Chi-Han Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
| | - Ya-Ting Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
| | - Kuo-Tung Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
| | - Yi-His Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chin-Chou Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Niaosung, Kaohsiung, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- * E-mail: (WFF); (MCL)
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41
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Schmidt EP, Overdier KH, Sun X, Lin L, Liu X, Yang Y, Ammons LA, Hiller TD, Suflita MA, Yu Y, Chen Y, Zhang F, Cothren Burlew C, Edelstein CL, Douglas IS, Linhardt RJ. Urinary Glycosaminoglycans Predict Outcomes in Septic Shock and Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 194:439-49. [PMID: 26926297 DOI: 10.1164/rccm.201511-2281oc] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
RATIONALE Degradation of the endothelial glycocalyx, a glycosaminoglycan (GAG)-rich layer lining the vascular lumen, is associated with the onset of kidney injury in animal models of critical illness. It is unclear if similar pathogenic degradation occurs in critically ill patients. OBJECTIVES To determine if urinary indices of GAG fragmentation are associated with outcomes in patients with critical illnesses such as septic shock or acute respiratory distress syndrome (ARDS). METHODS We prospectively collected urine from 30 patients within 24 hours of admission to the Denver Health Medical Intensive Care Unit (ICU) for septic shock. As a nonseptic ICU control, we collected urine from 25 surgical ICU patients admitted for trauma. As a medical ICU validation cohort, we obtained serially collected urine samples from 70 patients with ARDS. We performed mass spectrometry on urine samples to determine GAG (heparan sulfate, chondroitin sulfate, and hyaluronic acid) concentrations as well as patterns of heparan sulfate/chondroitin sulfate disaccharide sulfation. We compared these indices to measurements obtained using dimethylmethylene blue, an inexpensive, colorimetric urinary assay of sulfated GAGs. MEASUREMENTS AND MAIN RESULTS In septic shock, indices of GAG fragmentation correlated with both the development of renal dysfunction over the 72 hours after urine collection and with hospital mortality. This association remained after controlling for severity of illness and was similarly observed using the inexpensive dimethylmethylene blue assay. These predictive findings were corroborated using urine samples previously collected at three consecutive time points from patients with ARDS. CONCLUSIONS Early indices of urinary GAG fragmentation predict acute kidney injury and in-hospital mortality in patients with septic shock or ARDS. Clinical trial registered with www.clinicaltrials.gov (NCT01900275).
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Affiliation(s)
- Eric P Schmidt
- 1 Department of Medicine, and.,2 Department of Medicine, University of Colorado Denver, Aurora, Colorado; and
| | | | | | - Lei Lin
- 3 Department of Chemistry, and
| | | | - Yimu Yang
- 2 Department of Medicine, University of Colorado Denver, Aurora, Colorado; and
| | - Lee Anne Ammons
- 4 Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | | | - Matt A Suflita
- 5 Department of Biology, Rensselaer Polytechnic Institute, Troy, New York
| | | | | | | | | | - Charles L Edelstein
- 2 Department of Medicine, University of Colorado Denver, Aurora, Colorado; and
| | - Ivor S Douglas
- 1 Department of Medicine, and.,2 Department of Medicine, University of Colorado Denver, Aurora, Colorado; and
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42
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Abstract
PURPOSE Sepsis stimulates pro- and anti-inflammatory immune responses. The innate immune response is critical to organ injury repair. We tested for an association between innate immune function and organ function recovery in a prospective cohort of immune-competent adults with sepsis. METHODS We conducted a prospective observational cohort study enrolling immune-competent adults with sepsis. We tested innate immune function by quantification of lipopolysaccharide (LPS)-stimulated tumor necrosis factor (TNF) α production capacity in whole blood samples on hospital days 1, 4, and 6. The primary outcome was organ function recovery on day 4 defined as a 4-point decrease in the composite cardiovascular and respiratory Sequential Organ Failure Assessment (SOFA) score components or a SOFA score ≤2. RESULTS Patients with sepsis who recovered organ function by day 4 (n = 11) had similar baseline characteristics when compared to those with ongoing organ failure (n = 13). Tumor necrosis factor α production capacity was similar between the 2 groups on hospital days 1 and 4 but significantly different on day 6. Patients who regained organ function recovery had significantly higher TNF-α production capacity on day 6 ( P = .01), which persisted after adjustment for age, Acute Physiology and Chronic Health Evaluation III score, and steroid administration ( P = .03). There was no difference in TNF-α production capacity over time in those who survived to hospital discharge versus nonsurvivors. CONCLUSION Increasing TNF-α production capacity is associated with improved organ failure recovery. Further studies are needed to evaluate a causal association between innate immune suppression and organ failure recovery as well as predictive accuracy for hospital survival. Impaired TNF-α production as a marker of sepsis-associated innate immune dysfunction may be a feasible target for immune stimulation to decrease time to organ failure recovery.
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Affiliation(s)
- Aline B Maddux
- 1 Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO, USA.,2 Children's Hospital Colorado, Aurora, CO, USA
| | - Terra D Hiller
- 3 Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Katherine H Overdier
- 3 Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Laura L Pyle
- 1 Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO, USA.,4 Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Ivor S Douglas
- 1 Department of Pediatrics, Section of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO, USA.,3 Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, Denver Health Medical Center, Denver, CO, USA
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Abstract
In the USA alone, around 22 million patients annually discuss the need for surgical procedure with their surgeon. On a global scale, more than 200 million patients are exposed to the risk of undergoing a surgical procedure every year. A crucial part of the informed consent process for surgery is the understanding of risk, the probability of complications, and the predicted occurrence of adverse events. Ironically, risk quantification, risk stratification, and risk management are not necessarily part of a surgeon's core skillset, considering the lengthy surgical training curriculum towards technical excellence. The present review was designed to provide a concise historic perspective on the evolution of our current understanding of risk and probability, which represent the key underlying pillars of the shared decision-making process between surgeons and patients when discussing surgical treatment options.
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Affiliation(s)
- Philip F Stahel
- Department of Orthopaedics, University of Colorado, School of Medicine and Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204 USA.,Department of Neurosurgery, University of Colorado, School of Medicine and Denver Health Medical Center, Denver, CO 80204 USA
| | - Ivor S Douglas
- Department of Medicine, Division of Pulmonary Sciences and Critical Care, University of Colorado, School of Medicine and Denver Health Medical Center, Denver, CO 80204 USA
| | - Todd F VanderHeiden
- Department of Orthopaedics, University of Colorado, School of Medicine and Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204 USA
| | - Sebastian Weckbach
- Department of Orthopaedics, University Hospital Ulm, D-89081 Ulm, Germany
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44
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Lyon SM, Douglas IS, Cooke CR. Health Policy: Toward Achieving Respiratory Health Equality. Respir Med 2017. [DOI: 10.1007/978-3-319-43447-6_14] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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45
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Wilson KC, Gould MK, Krishnan JA, Boyd CM, Brozek JL, Cooke CR, Douglas IS, Goodman RA, Joo MJ, Lareau S, Mularski RA, Patel MR, Rosenfeld RM, Shanawani H, Slatore C, Sockrider M, Sufian B, Thomson CC, Wiener RS. An Official American Thoracic Society Workshop Report. A Framework for Addressing Multimorbidity in Clinical Practice Guidelines for Pulmonary Disease, Critical Illness, and Sleep Disorders. Ann Am Thorac Soc 2016; 13:S12-21. [PMID: 26963362 PMCID: PMC5884100 DOI: 10.1513/annalsats.201601-007st] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 01/06/2023] Open
Abstract
Coexistence of multiple chronic conditions (i.e., multimorbidity) is the most common chronic health problem in adults. However, clinical practice guidelines have primarily focused on patients with a single disease, resulting in uncertainty about the care of patients with multimorbidity. The American Thoracic Society convened a workshop with the goal of establishing a strategy to address multimorbidity within clinical practice guidelines. In this Workshop Report, we describe a framework that addresses multimorbidity in each of the key steps of guideline development: topic selection, panel composition, identifying clinical questions, searching for and synthesizing evidence, rating the quality of that evidence, summarizing benefits and harms, formulating recommendations, and rating the strength of the recommendations. For the consideration of multimorbidity in guidelines to be successful and sustainable, the process must be both feasible and pragmatic. It is likely that this will be achieved best by the step-wise addition and refinement of the various components of the framework.
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Affiliation(s)
- Kevin C Wilson
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Michael K Gould
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Jerry A Krishnan
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Cynthia M Boyd
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Jan L Brozek
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Colin R Cooke
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Ivor S Douglas
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Richard A Goodman
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Min J Joo
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Suzanne Lareau
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Richard A Mularski
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Minal R Patel
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Richard M Rosenfeld
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Hasan Shanawani
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Christopher Slatore
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Marianna Sockrider
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Beth Sufian
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Carey C Thomson
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
| | - Renda Soylemez Wiener
- This official Workshop Report of the American Thoracic Society (ATS) was approved by the ATS Board of Directors December 2015
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Lammi MR, Aiello B, Burg GT, Rehman T, Douglas IS, Wheeler AP, deBoisblanc BP. Response to fluid boluses in the fluid and catheter treatment trial. Chest 2016; 148:919-926. [PMID: 26020673 DOI: 10.1378/chest.15-0445] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [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] Open
Abstract
BACKGROUND Recent emphasis has been placed on methods to predict fluid responsiveness, but the usefulness of using fluid boluses to increase cardiac index in critically ill patients with ineffective circulation or oliguria remains unclear. METHODS This retrospective analysis investigated hemodynamic responses of critically ill patients in the ARDS Network Fluid and Catheter Treatment Trial (FACTT) who were given protocol-based fluid boluses. Fluid responsiveness was defined as ≥ 15% increase in cardiac index after a 15 mL/kg fluid bolus. RESULTS A convenience sample of 127 critically ill patients enrolled in FACTT was analyzed for physiologic responses to 569 protocolized crystalloid or albumin boluses given for shock, low urine output (UOP), or low pulmonary artery occlusion pressure (PAOP). There were significant increases in mean central venous pressure (9.9 ± 4.5 to 11.1 ± 4.8 mm Hg, P < .0001) and mean PAOP (11.6 ± 3.6 to 13.3 ± 4.3 mm Hg, P < .0001) following fluid boluses. However, there were no significant changes in UOP, and there were clinically small changes in heart rate, mean arterial pressure, and cardiac index. Only 23% of fluid boluses led to a ≥ 15% change in cardiac index. There was no significant difference in the frequency of fluid responsiveness between boluses given for shock or oliguria vs boluses given only for low PAOP (24.0% vs 21.8%, P = .59). There were no significant differences in 90-day survival, need for hemodialysis, or return to unassisted breathing between patients defined as fluid responders and fluid nonresponders. CONCLUSIONS In this cohort of critically ill patients with ARDS who were previously resuscitated, the rate of fluid responsiveness was low, and fluid boluses only led to small hemodynamic changes.
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Affiliation(s)
- Matthew R Lammi
- Louisiana State University Health Sciences Center, New Orleans, LA.
| | - Brianne Aiello
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Gregory T Burg
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Tayyab Rehman
- Louisiana State University Health Sciences Center, New Orleans, LA
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47
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Maddux AB, Douglas IS. Is the developmentally immature immune response in paediatric sepsis a recapitulation of immune tolerance? Immunology 2015; 145:1-10. [PMID: 25691226 DOI: 10.1111/imm.12454] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 02/09/2015] [Accepted: 02/10/2015] [Indexed: 12/23/2022] Open
Abstract
Immunologically immature neonates suffer the highest incidence of paediatric sepsis. Postnatal immunological maturation is characterized by a relatively hypo-inflammatory immune response. The mechanisms that differentiate the mature and immature immune responses resemble those that differentiate the hyper- and hypo-inflammatory responses in severe sepsis. Immunological maturational differences likely affect the neonate's ability to mount an appropriate hyper-inflammatory response, a counteractive hypo-inflammatory response, and subsequent return to immune system homeostasis. To better understand the role of the hypo-inflammatory response in paediatric sepsis, we will explore the maturation of the immune system and the effect it may have on the sepsis-induced hypo-inflammatory response.
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Affiliation(s)
- Aline B Maddux
- Division of Pediatric Critical Care, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
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48
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Sun X, Li L, Overdier KH, Ammons LA, Douglas IS, Burlew CC, Zhang F, Schmidt EP, Chi L, Linhardt RJ. Analysis of Total Human Urinary Glycosaminoglycan Disaccharides by Liquid Chromatography-Tandem Mass Spectrometry. Anal Chem 2015; 87:6220-7. [PMID: 26005898 PMCID: PMC4822829 DOI: 10.1021/acs.analchem.5b00913] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [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] [Indexed: 12/16/2022]
Abstract
The determination of complex analytes, present at low concentrations, in biological fluids poses a difficult challenge. This study relies on an optimized method of recovery, enzymatic treatment, and disaccharide analysis by liquid chromatography-tandem mass spectrometry to rapidly determine low concentrations of glycosaminoglycans in human urine. The approach utilizes multiple reaction monitoring (MRM) of glycosaminoglycan disaccharides obtained from treating urine samples with recombinant heparin lyases and chondroitin lyase. This rapid and sensitive method allows the analysis of glycosaminoglycan content and disaccharide composition in urine samples having concentrations 10- to 100-fold lower than those typically analyzed from patients with metabolic diseases, such as mucopolysaccharidosis. The current method facilitates the analysis low (ng/mL) levels of urinary glycosaminoglycans present in healthy individuals and in patients with pathological conditions, such as inflammation and cancers, that can subtly alter glycosaminoglycan content and composition.
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Affiliation(s)
- Xiaojun Sun
- National Glycoengineering Research Center, Shandong University, Jinan 250100, China
- Department of Chemistry and Chemical Biology, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York 12180, United States
| | - Lingyun Li
- Department of Chemistry and Chemical Biology, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York 12180, United States
- Wadsworth Center, New York State Department of Health, Albany, New York 12201, United States
| | - Katherine H. Overdier
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Denver, Colorado 80204, United States
| | - Lee Anne Ammons
- Department of Surgery, Denver Health Medical Center, Denver, Colorado 80204, United States
| | - Ivor S. Douglas
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Denver, Colorado 80204, United States
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, Denver, Colorado 80204, United States
| | - Fuming Zhang
- Department of Chemical and Biological Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York 12180, United States
| | - Eric P. Schmidt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Denver, Colorado 80204, United States
- Program in Translational Lung Research, Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
| | - Lianli Chi
- National Glycoengineering Research Center, Shandong University, Jinan 250100, China
| | - Robert J. Linhardt
- Department of Chemistry and Chemical Biology, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York 12180, United States
- Department of Chemical and Biological Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York 12180, United States
- Department of Biology, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York 12180, United States
- Department of Biomedical Engineering, Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, New York 12180, United States
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Douglas IS, Price CS, Overdier KH, Wolken RF, Metzger SW, Hance KR, Howson DC. Rapid automated microscopy for microbiological surveillance of ventilator-associated pneumonia. Am J Respir Crit Care Med 2015; 191:566-73. [PMID: 25585163 DOI: 10.1164/rccm.201408-1468oc] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Diagnosis of ventilator-associated pneumonia (VAP) is imprecise. OBJECTIVES To (1) determine whether alternate-day surveillance mini-bronchoalveolar lavage (mini-BAL) in ventilated adults could reduce time to initiation of targeted treatment and (2) evaluate the potential for automated microscopy to reduce analysis time. METHODS Adult intensive care unit patients who were anticipated to require ventilation for at least a further 48 hours were included. Mini-BALs were processed for identification, quantitation, and antibiotic susceptibility, using (1) clinical culture (50 ± 7 h) and (2) automated microscopy (∼5 h plus offline analysis). MEASUREMENTS AND MAIN RESULTS Seventy-seven mini-BALs were performed in 33 patients. One patient (3%) was clinically diagnosed with VAP. Of 73 paired samples, culture identified 7 containing pneumonia panel bacteria (>10(4) colony-forming units/ml) from five patients (15%) (4 Staphylococcus aureus [3 methicillin-resistant S. aureus], 2 Stenotrophomonas maltophilia, 1 Klebsiella pneumoniae) and resulted in antimicrobial changes/additions to two of five (40%) of those patients. Microscopy identified 7 of 7 microbiologically positive organisms and 64 of 66 negative samples compared with culture. Antimicrobial responses were concordant in four of five comparisons. Antimicrobial changes/additions would have occurred in three of seven microscopy-positive patients (43%) had those results been clinically available in 5 hours, including one patient diagnosed later with VAP despite negative mini-BAL cultures. CONCLUSIONS Microbiological surveillance detected infection in patients at risk for VAP independent of clinical signs, resulting in changes to antimicrobial therapy. Automated microscopy was 100% sensitive and 97% specific for high-risk pneumonia organisms compared with clinical culturing. Rapid microscopy-based surveillance may be informative for treatment and antimicrobial stewardship in patients at risk for VAP.
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Affiliation(s)
- Ivor S Douglas
- 1 Division of Pulmonary Sciences and Critical Care Medicine
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50
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Goodson CM, Clark BJ, Douglas IS. Predictors of Severe Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis. Alcohol Clin Exp Res 2014; 38:2664-77. [DOI: 10.1111/acer.12529] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 07/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Carrie M. Goodson
- University of Colorado School of Medicine; Denver Colorado
- Denver Health Medical Center, Department of Medicine; Denver Colorado
| | | | - Ivor S. Douglas
- University of Colorado School of Medicine; Denver Colorado
- Denver Health Medical Center, Department of Medicine; Denver Colorado
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