1
|
O'Gara BP, Tung MG, Kennedy KF, Espinosa-Leon JP, Shaefi S, Gluck J, Raz Y, Seethala R, Reich JA, Faugno AJ, Brodie D, Garan AR, Grandin EW. Outcomes With Single-Site Dual-Lumen Versus Multisite Cannulation for Adults With COVID-19 Respiratory Failure Receiving Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med 2023; 51:1716-1726. [PMID: 37548506 DOI: 10.1097/ccm.0000000000006014] [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: 08/08/2023]
Abstract
OBJECTIVES To determine whether multisite versus single-site dual-lumen (SSDL) cannulation is associated with outcomes for COVID-19 patients requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). DESIGN Retrospective analysis of the Extracorporeal Life Support Organization Registry. Propensity score matching (2:1 multisite vs SSDL) was used to control for confounders. PATIENTS The matched cohort included 2,628 patients (1,752 multisite, 876 SSDL) from 170 centers. The mean ( sd ) age in the entire cohort was 48 (11) years, and 3,909 (71%) were male. Patients were supported with mechanical ventilation for a median (interquartile range) of 79 (113) hours before VV-ECMO support. INTERVENTIONS None. MEASUREMENTS The primary outcome was 90-day survival. Secondary outcomes included survival to hospital discharge, duration of ECMO support, days free of ECMO support at 90 days, and complication rates. MAIN RESULTS There was no difference in 90-day survival (49.4 vs 48.9%, p = 0.66), survival to hospital discharge (49.8 vs 48.2%, p = 0.44), duration of ECMO support (17.9 vs 17.1 d, p = 0.82), or hospital length of stay after cannulation (28 vs 27.4 d, p = 0.37) between multisite and SSDL groups. More SSDL patients were extubated within 24 hours (4% vs 1.9%, p = 0.001). Multisite patients had higher ECMO flows at 24 hours (4.5 vs 4.1 L/min, p < 0.001) and more ECMO-free days at 90 days (3.1 vs 2.0 d, p = 0.02). SSDL patients had higher rates of pneumothorax (13.9% vs 11%, p = 0.03). Cannula site bleeding (6.4% vs 4.7%, p = 0.03), oxygenator failure (16.7 vs 13.4%, p = 0.03), and circuit clots (5.5% vs 3.4%, p = 0.02) were more frequent in multisite patients. CONCLUSIONS In this retrospective study of COVID-19 patients requiring VV-ECMO, 90-day survival did not differ between patients treated with a multisite versus SSDL cannulation strategy and there were only modest differences in major complication rates. These findings do not support the superiority of either cannulation strategy in this setting.
Collapse
Affiliation(s)
- Brian P O'Gara
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Matthew G Tung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Kevin F Kennedy
- Department of Medicine, Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Juan P Espinosa-Leon
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jason Gluck
- Division of Cardiovascular Medicine, Department of Medicine, Hartford Hospital, Hartford, CT
| | - Yuval Raz
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Raghu Seethala
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - John A Reich
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Anthony J Faugno
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Daniel Brodie
- Division of Critical Care Medicine and Pulmonary, Department of Medicine, Columbia University Medical Center, New York, NY
| | - A Reshad Garan
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - E Wilson Grandin
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
2
|
Seeliger B, Bode C, Shaefi S, Hofmaenner DA, David S. D-dimer trends in ECMO patients: don't shoot the messenger. Intensive Care Med 2023; 49:1563-1564. [PMID: 37906256 DOI: 10.1007/s00134-023-07258-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/02/2023]
Affiliation(s)
- Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel A Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
3
|
Esmaeeli S, Motayagheni N, Bastos AB, Ogilvy CS, Thomas AJ, Pollard R, Buhl LK, Baker MB, Phan S, Hassan O, Fehnel CR, Eikermann M, Shaefi S, Nozari A. Propofol-Based Anesthesia Maintenance and/or Volatile Anesthetics during Intracranial Aneurysm Repair: A Comparative Analysis of Neurological Outcomes. J Clin Med 2023; 12:6954. [PMID: 37959418 PMCID: PMC10648155 DOI: 10.3390/jcm12216954] [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] [Received: 10/05/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Volatile and intravenous anesthetics have substantial effects on physiological functions, notably influencing neurological function and susceptibility to injury. Despite the importance of the anesthetic approach, data on its relative risks or benefits during surgical clipping or endovascular treatments for unruptured intracranial aneurysms (UIAs) remains scant. We investigated whether using volatile anesthetics alone or in combination with propofol infusion yields superior neurological outcomes following UIA obliteration. METHODS We retrospectively reviewed 1001 patients who underwent open or endovascular treatment for UIA, of whom 596 had short- and long-term neurological outcome data (modified Rankin Scale) recorded. Multivariable ordinal regression analysis was performed to examine the association between the anesthetic approach and outcomes. RESULTS Of 1001 patients, 765 received volatile anesthetics alone, while 236 received propofol infusion and volatile anesthetics (combined anesthetic group). Short-term neurological outcome data were available for 619 patients and long-term data for 596. No significant correlation was found between the anesthetic approach and neurologic outcomes, irrespective of the type of procedure (open craniotomy or endovascular treatment). The combined anesthetic group had a higher rate of ICU admission (p < 0.001) and longer ICU and hospital length of stay (LOS, p < 0.001). Similarly, a subgroup analysis revealed longer ICU and hospital LOS (p < 0.0001 and p < 0.001, respectively) in patients who underwent endovascular UIA obliteration under a combined anesthetic approach (n = 678). CONCLUSIONS The addition of propofol to volatile anesthetics during UIA obliteration does not provide short- or long-term benefits to neurologic outcomes. Compared to volatile anesthetics alone, the combination of propofol and volatile anesthetics may be associated with an increased rate of ICU admission, as well as longer ICU and hospital LOS.
Collapse
Affiliation(s)
- Shooka Esmaeeli
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (R.P.); (S.S.)
- Department of Anesthesiology, Boston Medical Center, Boston University, Boston, MA 02118, USA; (S.E.); (M.B.B.)
| | - Negar Motayagheni
- Heart Transplant Program, Cedars-Sinai California Heart Center, Beverly Hills, CA 90211, USA;
| | - Andres Brenes Bastos
- Department of Anesthesiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT 06510, USA;
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA;
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ 08103, USA;
| | - Richard Pollard
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (R.P.); (S.S.)
| | - Lauren K Buhl
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Hanover, NH 03766, USA
| | - Maxwell B Baker
- Department of Anesthesiology, Boston Medical Center, Boston University, Boston, MA 02118, USA; (S.E.); (M.B.B.)
| | - Sheshanna Phan
- Department of Internal Medicine, University of New Mexico Hospital, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA;
| | - Omron Hassan
- Department of Internal Medicine, Freeman Hospital, Joplin, MO 64804, USA
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Critical Care, Pain Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA;
| | - Shahzad Shaefi
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (R.P.); (S.S.)
| | - Ala Nozari
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (R.P.); (S.S.)
- Department of Anesthesiology, Boston Medical Center, Boston University, Boston, MA 02118, USA; (S.E.); (M.B.B.)
| |
Collapse
|
4
|
Abess AT, Deiner SG, Briggs A, Whitlock EL, Charette KE, Chow VW, Shaefi S, Martinez-Camblor P, O'Malley AJ, Boone MD. Association of neurocognitive disorders with morbidity and mortality in older adults undergoing major surgery in the USA: a retrospective, population-based, cohort study. Lancet Healthy Longev 2023; 4:e608-e617. [PMID: 37924842 PMCID: PMC10654795 DOI: 10.1016/s2666-7568(23)00194-0] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Neurocognitive disorders become increasingly common as patients age, and increasing numbers of surgical interventions are done on older patients. The aim of this study was to understand the clinical characteristics and outcomes of surgical patients with neurocognitive disorders in the USA in order to guide future targeted interventions for better care. METHODS This retrospective cohort study used claims data for US Medicare beneficiaries aged 65 years and older with a record of inpatient admission for a major diagnostic or therapeutic surgical procedure between Jan 1, 2017, and Dec 31, 2018. Data were retrieved through a data use agreement between Dartmouth Hitchcock Medical Center and US Centers for Medicare and Medicaid Services via the Research Data Assistance Center. The exposure of interest was the presence of a pre-existing neurocognitive disorder as defined by diagnostic code within 3 years of index hospital admission. The primary outcome was mortality at 30 days, 90 days, and 365 days from date of surgery among all patients with available data. FINDINGS Among 5 263 264 Medicare patients who underwent a major surgical procedure, 767 830 (14·59%) had a pre-existing neurocognitive disorder and 4 495 434 (85·41%) had no pre-existing neurocognitive disorder. Adjusting for demographic factors and comorbidities, patients with a neurocognitive disorder had higher 30-day (hazard ratio 1·24 [95% CI 1·23-1·25]; p<0·0001), 90-day (1·25 [1·24-1·26]; p<0·0001), and 365-day mortality (1·25 [1·25-1·26]; p<0·0001) compared with patients without a neurocognitive disorder. INTERPRETATION Our findings suggest that the presence of a neurocognitive disorder is independently associated with an increased risk of mortality. Identification of a neurocognitive disorder before surgery can help clinicians to better disclose risks and plan for patient care after hospital discharge. FUNDING Department of Anesthesiology and Perioperative Medicine at Dartmouth Hitchcock Medical Center.
Collapse
Affiliation(s)
- Alexander T Abess
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
| | - Stacie G Deiner
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Alexandra Briggs
- Department of Surgery, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Elizabeth L Whitlock
- Department of Anesthesia and Perioperative Care, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Kristin E Charette
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Vinca W Chow
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Pablo Martinez-Camblor
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Alistair James O'Malley
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Myles Dustin Boone
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| |
Collapse
|
5
|
Wiredu K, Mueller A, McKay TB, Behera A, Shaefi S, Akeju O. Sex Differences in the Incidence of Postoperative Delirium after Cardiac Surgery: A Pooled Analyses of Clinical Trials. Anesthesiology 2023; 139:540-542. [PMID: 37535937 PMCID: PMC10529077 DOI: 10.1097/aln.0000000000004656] [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] [Indexed: 08/05/2023]
Affiliation(s)
- Kwame Wiredu
- Massachusetts General Hospital, Boston, Massachusetts (K.W.).
| | | | | | | | | | | |
Collapse
|
6
|
Siddiqui S, Warner MA, Kelly L, Novack V, Monteith E, Douin DJ, Mladinov D, Shaefi S, Stevens RD, Tung A, Sladen RN. Determinants of Professional Fulfillment and Burnout Among Intensivists: A National Survey by the Society of Critical Care Anesthesiologists in 2022. Anesth Analg 2023; 137:375-382. [PMID: 36791019 PMCID: PMC10363231 DOI: 10.1213/ane.0000000000006384] [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: 02/16/2023]
Abstract
BACKGROUND Increased burnout and decreased professional fulfillment among intensive care physicians is partly due to intensive care unit (ICU) workload. Although the SARS-CoV-2 (COVID-19) pandemic increased ICU workload, it also may have increased feelings of personal fulfillment due to positive public perceptions of physicians caring for COVID patients. We surveyed critical care anesthesiologists to identify the effect of provider demographics, ICU workload, and COVID-19-related workload, on professional fulfillment and burnout. METHODS We performed an exploratory survey of 606 members of the Society of Critical Care Anesthesiologists (SOCCA) in January and February 2022. We used the Stanford Professional Fulfillment Index (PFI) to grade levels of professional fulfillment and markers of burnout (ie, work exhaustion and disengagement). Univariable and multivariable models were used to identify associations between provider demographics and practice characteristics and professional fulfillment and work exhaustion. RESULTS One hundred and seventy-five intensivists (29%) responded. A total of 65% were male and 49% were between 36 and 45 years old. The overall median PFI score-0 (none) to 24 (most professional fulfillment)-was 17 (IQR, 1-24), with a wide distribution of responses. In multivariable analysis, factors associated with higher professional fulfillment included age >45 years ( P =.004), ≤15 weeks full-time ICU coverage in 2020 ( P =.02), role as medical director ( P =.01), and nighttime home call with supervision of in-house ICU fellows ( P =.01). CONCLUSIONS Professional fulfillment and work exhaustion in this cross-sectional survey were associated with several demographic and practice characteristics but not COVID-19-related workload, suggesting that COVID-19 workload may not have either positive or negative perceptions on professional fulfillment.
Collapse
Affiliation(s)
- Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, MN, USA
| | - Lauren Kelly
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Victor Novack
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Erika Monteith
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - David J. Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama, Birmingham, AL, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, IL, USA
| | - Robert N. Sladen
- Division of Critical Care Medicine, Department of Anesthesiology, Columbia University Irvine Medical Center, NY, USA
| |
Collapse
|
7
|
Wiredu K, O’Connor S, Naseem H, Brauer BL, Kettenbach AN, Frost HR, Shaefi S, Gerber SA. Intraoperative plasma proteomic changes in cardiac surgery: In search of biomarkers of post-operative delirium. Proteomics Clin Appl 2023; 17:e2200066. [PMID: 36567636 PMCID: PMC10290728 DOI: 10.1002/prca.202200066] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/02/2022] [Accepted: 12/21/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE Delirium presents a significant healthcare burden. It complicates post-operative care in up to 50% of cardiac surgical patients with worse outcomes, longer hospital stays and higher cost of care. Moreover, the nature of delirium following cardiac surgery with cardiopulmonary bypass (CPB) remains unclear, the underlying pathobiology is poorly understood, status quo diagnostic methods are subjective, and diagnostic biomarkers are currently lacking. OBJECTIVE To identify diagnostic biomarkers of delirium and for insights into possible neuronal pathomechanisms. EXPERIMENTAL DESIGN Comparative proteomic analyses were performed on plasma samples from a nested matched cohort of patients who underwent cardiac surgery. Validation by targeted proteomics was performed in an independent set of samples. Biomarkers were assessed for biological functions and diagnostic accuracy. RESULTS Forty-seven percent of subjects demonstrated delirium. Of 3803 proteins identified from patient samples by multiplexed quantitative proteomics, 16 were identified as signatures of exposure to CPB, and 11 biomarkers distinguished delirium cases from non-cases (AuROC = 93%). Notable among these biomarkers are C-reactive protein, serum amyloid A-1 and cathepsin-B. CONCLUSIONS AND CLINICAL RELEVANCE The interplay of systemic and central inflammatory markers sheds new light on delirium pathogenesis. This work suggests that accurate identification of cases may be achievable using panels of biomarkers.
Collapse
Affiliation(s)
- Kwame Wiredu
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Anesthesia, Critical Care and Pain Medicine, Mass General Hospital, Boston MA
- Department of Anaesthesia, Harvard Medical School, Boston MA
| | - Sean O’Connor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Heba Naseem
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Brooke L. Brauer
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Arminja N. Kettenbach
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Hildreth R. Frost
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Shahzad Shaefi
- Department of Anaesthesia, Harvard Medical School, Boston MA
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - Scott A. Gerber
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Department of Biochemistry and Cell Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| |
Collapse
|
8
|
Green A, Rachoin JS, Schorr C, Dellinger P, Casey JD, Park I, Gupta S, Baron RM, Shaefi S, Hunter K, Leaf DE. Timing of invasive mechanical ventilation and death in critically ill adults with COVID-19: A multicenter cohort study. PLoS One 2023; 18:e0285748. [PMID: 37379286 DOI: 10.1371/journal.pone.0285748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/02/2023] [Indexed: 06/30/2023] Open
Abstract
PURPOSE To investigate if the timing of initiation of invasive mechanical ventilation (IMV) for critically ill patients with COVID-19 is associated with mortality. MATERIALS AND METHODS The data for this study were derived from a multicenter cohort study of critically ill adults with COVID-19 admitted to ICUs at 68 hospitals across the US from March 1 to July 1, 2020. We examined the association between early (ICU days 1-2) versus late (ICU days 3-7) initiation of IMV and time-to-death. Patients were followed until the first of hospital discharge, death, or 90 days. We adjusted for confounding using a multivariable Cox model. RESULTS Among the 1879 patients included in this analysis (1199 male [63.8%]; median age, 63 [IQR, 53-72] years), 1526 (81.2%) initiated IMV early and 353 (18.8%) initiated IMV late. A total of 644 of the 1526 patients (42.2%) in the early IMV group died, and 180 of the 353 (51.0%) in the late IMV group died (adjusted HR 0.77 [95% CI, 0.65-0.93]). CONCLUSIONS In critically ill adults with respiratory failure from COVID-19, early compared to late initiation of IMV is associated with reduced mortality.
Collapse
Affiliation(s)
- Adam Green
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jean-Sebastien Rachoin
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Christa Schorr
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Phil Dellinger
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - Jonathan D Casey
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Isabel Park
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Rebecca M Baron
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Krystal Hunter
- Cooper University Health Care and Cooper Medical School of Rowan University, Camden, NJ, United States of America
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
| |
Collapse
|
9
|
Hofmaenner DA, Furfaro D, Wild LC, Wendel-Garcia PD, Baedorf Kassis E, Pannu A, Welte T, Erlebach R, Stahl K, Grandin EW, Putensen C, Schuepbach RA, Shaefi S, David S, Seeliger B, Bode C. Reduced anticoagulation strategy is associated with a lower incidence of intracerebral hemorrhage in COVID-19 patients on extracorporeal membrane oxygenation. Intensive Care Med Exp 2023; 11:38. [PMID: 37302996 DOI: 10.1186/s40635-023-00525-3] [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] [Received: 03/03/2023] [Accepted: 05/18/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Optimal anticoagulation strategies for COVID-19 patients with the acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) remain uncertain. A higher incidence of intracerebral hemorrhage (ICH) during VV ECMO support compared to non-COVID-19 viral ARDS patients has been reported, with increased bleeding rates in COVID-19 attributed to both intensified anticoagulation and a disease-specific endotheliopathy. We hypothesized that lower intensity of anticoagulation during VV ECMO would be associated with a lower risk of ICH. In a retrospective, multicenter study from three academic tertiary intensive care units, we included patients with confirmed COVID-19 ARDS requiring VV ECMO support from March 2020 to January 2022. Patients were grouped by anticoagulation exposure into higher intensity, targeting anti-factor Xa activity (anti-Xa) of 0.3-0.4 U/mL, versus lower intensity, targeting anti-Xa 0.15-0.3 U/mL, cohorts. Mean daily doses of unfractionated heparin (UFH) per kg bodyweight and effectively measured daily anti-factor Xa activities were compared between the groups over the first 7 days on ECMO support. The primary outcome was the rate of ICH during VV ECMO support. RESULTS 141 critically ill COVID-19 patients were included in the study. Patients with lower anticoagulation targets had consistently lower anti-Xa activity values over the first 7 ECMO days (p < 0.001). ICH incidence was lower in patients in the lower anti-Xa group: 4 (8%) vs 32 (34%) events. Accounting for death as a competing event, the adjusted subhazard ratio for the occurrence of ICH was 0.295 (97.5% CI 0.1-0.9, p = 0.044) for the lower anti-Xa compared to the higher anti-Xa group. 90-day ICU survival was higher in patients in the lower anti-Xa group, and ICH was the strongest risk factor associated with mortality (odds ratio [OR] 6.8 [CI 2.1-22.1], p = 0.001). CONCLUSIONS For COVID-19 patients on VV ECMO support anticoagulated with heparin, a lower anticoagulation target was associated with a significant reduction in ICH incidence and increased survival.
Collapse
Affiliation(s)
- Daniel A Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - David Furfaro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lennart C Wild
- Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Pedro David Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Elias Baedorf Kassis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ameeka Pannu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Edward Wilson Grandin
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Christian Putensen
- Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Benjamin Seeliger
- Department of Respiratory Medicine, Hannover Medical School and Member of the German Centre for Lung Research, Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - Christian Bode
- Department of Anesthesia and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
10
|
Glaser A, Kanter J, Martinez-Camblor P, Buhl L, Anderson M, Pannu A, Shaefi S, Taenzer A, Boone MD. 775 The Effect of Anti-Seizure Medication Administration on Mortality and Early Post Traumatic Seizures In Critically Ill Older Adults With Traumatic Brain Injury. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
|
11
|
Wiredu K, Aduse-Poku E, Shaefi S, Gerber SA. Proteomics for the Discovery of Clinical Delirium Biomarkers: A Systematic Review of Major Studies. Anesth Analg 2023; 136:422-432. [PMID: 36580411 DOI: 10.1213/ane.0000000000006246] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Delirium represents a significant health care burden, diagnosed in more than 2 million elderly Americans each year. In the surgical population, delirium remains the most common complication among elderly patients, and is associated with longer hospital stays, higher costs of care, increased mortality, and functional impairment. The pathomechanism of disease is poorly understood, with current diagnostic approaches somewhat subjective and arbitrary, and definitive diagnostic biomarkers are currently lacking. Despite the recent interest in delirium research, biomarker discovery for it remains new. Most attempts to discover biomarkers are targeted studies that seek to assess the involvement of one or more members of a focused panel of candidates in delirium. For a more unbiased, system-biology view, we searched literature from Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Central, Web of Science, SCOPUS, and Dimensions between 2016 and 2021 for untargeted proteomic discovery studies for biomarkers of delirium conducted on human geriatric subjects. Two reviewers conducted an independent review of all search results and resolved discordance by consensus. From an overall search of 1172 publications, 8 peer-reviewed studies met our defined inclusion criteria. The 370 unique perioperative biomarkers identified in these reports are enriched in pathways involving activation of the immune system, inflammatory response, and the coagulation cascade. The most frequently identified biomarker was interleukin-6 (IL-6). By reviewing the distribution of protein biomarker candidates from these studies, we conclude that a panel of proteins, rather than a single biomarker, would allow for discriminating delirium cases from noncases. The paucity of hypothesis-generating studies in the peer-reviewed literature also suggests that a system-biology view of delirium pathomechanisms has yet to fully emerge.
Collapse
Affiliation(s)
- Kwame Wiredu
- From the Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Program in Quantitative Biomedical Science, Dartmouth College, Hanover, New Hampshire
| | | | - Shahzad Shaefi
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School/Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Scott A Gerber
- From the Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.,Program in Quantitative Biomedical Science, Dartmouth College, Hanover, New Hampshire.,Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| |
Collapse
|
12
|
Bartels K, Howard-Quijano K, Prin M, Shaefi S, Steppan J, Sun EC, Williams B, Fox AA, Namuyonga J, Shaw AD, Vavilala MS, Sessler DI. Meeting Report: First Cardiovascular Outcomes Research in Perioperative Medicine Conference. Anesth Analg 2023; 136:418-420. [PMID: 36638519 PMCID: PMC9846581 DOI: 10.1213/ane.0000000000006248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The first Cardiovascular Outcomes Research in Perioperative Medicine (COR-PM) conference took place on May 13, 2022, in Palm Springs, CA, and online. Here, we: (1) summarize the background, objective, and aims of the COR-PM meeting; (2) describe the conduct of the meeting; and (3) outline future directions for scientific meetings aimed at fostering high-quality clinical research in the broader perioperative medicine community.
Collapse
Affiliation(s)
- Karsten Bartels
- Department of Anesthesiology, University of Nebraska
Medical Center, Omaha, NE, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | | | - Meghan Prin
- Department of Anesthesiology, University of Colorado,
School of Medicine, Aurora, CO, USA
| | - Shahzad Shaefi
- Department of Anesthesiology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Eric C. Sun
- Department of Anesthesiology, Perioperative and Pain
Medicine, Stanford University, Palo Alto, CA, USA
| | - Brittney Williams
- Department of Anesthesiology, University of Maryland,
Baltimore, MD, USA
| | - Amanda A. Fox
- Department of Anesthesiology and Pain Management, UT
Southwestern Medical Center, Dallas, TX, USA
| | - Judith Namuyonga
- Department of Cardiology, Uganda Heart Institute, Kampala,
Uganda
| | - Andrew D. Shaw
- Department of Intensive Care and Resuscitation, Cleveland
Clinic, Cleveland, OH, USA
| | - Monica S. Vavilala
- Department of Anesthesiology, University of Washington,
Seattle, WA, USA
| | - Daniel I. Sessler
- Department of Outcomes Research, Cleveland Clinic,
Cleveland, OH, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| |
Collapse
|
13
|
Shaefi S, Pannu A, Mueller AL, Flynn B, Evans A, Jabaley CS, Mladinov D, Wall M, Siddiqui S, Douin DJ, Boone MD, Monteith E, Abalama V, Nunnally ME, Cobas M, Warner MA, Stevens RD. Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians: A Survey to Members of the Society of Critical Care Anesthesiologists. Anesth Analg 2023; 136:295-307. [PMID: 35950751 PMCID: PMC9840646 DOI: 10.1213/ane.0000000000006160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite the growing contributions of critical care anesthesiologists to clinical practice, research, and administrative leadership of intensive care units (ICUs), relatively little is known about the subspecialty-specific clinical practice environment. An understanding of contemporary clinical practice is essential to recognize the opportunities and challenges facing critical care anesthesia, optimize staffing patterns, assess sustainability and satisfaction, and strategically plan for future activity, scope, and training. This study surveyed intensivists who are members of the Society of Critical Care Anesthesiologists (SOCCA) to evaluate practice patterns of critical care anesthesiologists, including compensation, types of ICUs covered, models of overnight ICU coverage, and relationships between these factors. We hypothesized that variability in compensation and practice patterns would be observed between individuals. METHODS Board-certified critical care anesthesiologists practicing in the United States were identified using the SOCCA membership distribution list and invited to take a voluntary online survey between May and June 2021. Multiple-choice questions with both single- and multiple-select options were used for answers with categorical data, and adaptive questioning was used to clarify stem-based responses. Respondents were asked to describe practice patterns at their respective institutions and provide information about their demographics, salaries, effort in ICUs, as well as other activities. RESULTS A total of 490 participants were invited to take this survey, and 157 (response rate 32%) surveys were completed and analyzed. The majority of respondents were White (73%), male (69%), and younger than 50 years of age (82%). The cardiothoracic/cardiovascular ICU was the most common practice setting, with 69.5% of respondents reporting time working in this unit. Significant variability was observed in ICU practice patterns. Respondents reported spending an equal proportion of their time in clinical practice in the operating rooms and ICUs (median, 40%; interquartile range [IQR], 20%-50%), whereas a smaller proportion-primarily those who completed their training before 2009-reported administrative or research activities. Female respondents reported salaries that were $36,739 less than male respondents; however, this difference was not statistically different, and after adjusting for age and practice type, these differences were less pronounced (-$27,479.79; 95% confidence interval [CI], -$57,232.61 to $2273.03; P = .07). CONCLUSIONS These survey data provide a current snapshot of anesthesiology critical care clinical practice patterns in the United States. Our findings may inform decision-making around the initiation and expansion of critical care services and optimal staffing patterns, as well as provide a basis for further work that focuses on intensivist satisfaction and burnout.
Collapse
Affiliation(s)
- Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ameeka Pannu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ariel L. Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brigid Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | | | - Craig S. Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, Atlanta, GA
| | - Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama Hospital, Birmingham, AL
| | - Michael Wall
- Department of Anesthesiology, University of Minnesota Medical Center, Minneapolis, MN
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David J. Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - M. Dustin Boone
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Erika Monteith
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vivian Abalama
- International Anesthesia Research Society (IARS), Society of Critical Care Anesthesiologists (SOCCA), San Francisco, CA
| | - Mark E. Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY
| | - Miguel Cobas
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Jackson Memorial Hospital, Miami, FL
| | - Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
14
|
Qu JZ, Mueller A, McKay TB, Westover MB, Shelton KT, Shaefi S, D'Alessandro DA, Berra L, Brown EN, Houle TT, Akeju O. Nighttime dexmedetomidine for delirium prevention in non-mechanically ventilated patients after cardiac surgery (MINDDS): A single-centre, parallel-arm, randomised, placebo-controlled superiority trial. EClinicalMedicine 2023; 56:101796. [PMID: 36590787 PMCID: PMC9800196 DOI: 10.1016/j.eclinm.2022.101796] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The delirium-sparing effect of nighttime dexmedetomidine has not been studied after surgery. We hypothesised that a nighttime dose of dexmedetomidine would reduce the incidence of postoperative delirium as compared to placebo. METHODS This single-centre, parallel-arm, randomised, placebo-controlled superiority trial evaluated whether a short nighttime dose of intravenous dexmedetomidine (1 μg/kg over 40 min) would reduce the incidence of postoperative delirium in patients 60 years of age or older undergoing elective cardiac surgery with cardiopulmonary bypass. Patients were randomised to receive dexmedetomidine or placebo in a 1:1 ratio. The primary outcome was delirium on postoperative day one. Secondary outcomes included delirium within three days of surgery, 30-, 90-, and 180-day abbreviated Montreal Cognitive Assessment scores, Patient Reported Outcome Measures Information System quality of life scores, and all-cause mortality. The study was registered as NCT02856594 on ClinicalTrials.gov on August 5, 2016, before the enrolment of any participants. FINDINGS Of 469 patients that underwent randomisation to placebo (n = 235) or dexmedetomidine (n = 234), 75 met a prespecified drop criterion before the study intervention. Thus, 394 participants (188 dexmedetomidine; 206 placebo) were analysed in the modified intention-to-treat cohort (median age 69 [IQR 64, 74] years; 73.1% male [n = 288]; 26·9% female [n = 106]). Postoperative delirium status on day one was missing for 30 (7.6%) patients. Among those in whom it could be assessed, the primary outcome occurred in 5 of 175 patients (2.9%) in the dexmedetomidine group and 16 of 189 patients (8.5%) in the placebo group (OR 0.32, 95% CI: 0.10-0.83; P = 0.029). A non-significant but higher proportion of participants experienced delirium within three days postoperatively in the placebo group (25/177; 14.1%) compared to the dexmedetomidine group (14/160; 8.8%; OR 0.58; 95% CI, 0.28-1.15). No significant differences between groups were observed in secondary outcomes or safety. INTERPRETATION Our findings suggested that in elderly cardiac surgery patients with a low baseline risk of postoperative delirium and extubated within 12 h of ICU admission, a short nighttime dose of dexmedetomidine decreased the incidence of delirium on postoperative day one. Although non-statistically significant, our findings also suggested a clinical meaningful difference in the three-day incidence of postoperative delirium. FUNDING National Institute on Aging (R01AG053582).
Collapse
Affiliation(s)
- Jason Z. Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tina B. McKay
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth T. Shelton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David A. D'Alessandro
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Respiratory Care Services, Massachusetts General Hospital, Boston, MA, USA
| | - Emery N. Brown
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Timothy T. Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Corresponding author. Massachusetts General Hospital, 55 Fruit Street, Gray Bigelow 444, Boston, MA 02114, USA.
| | | |
Collapse
|
15
|
O'Gara BP, Beydoun NY, Mueller A, Kumaresan A, Shaefi S. Anesthetic Preferences for Cardiac Anesthesia: A Survey of the Society of Cardiovascular Anesthesiologists. Anesth Analg 2023; 136:51-59. [PMID: 35819157 PMCID: PMC9771889 DOI: 10.1213/ane.0000000000006147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Volatile anesthetics have been historically preferred for cardiac anesthesia, but the evidence for their superiority to intravenous agents is mixed. We conducted a survey to better understand the current state of practice and the rationale behind provider preferences for anesthesia for cardiac surgery with cardiopulmonary bypass. We hypothesized that anesthetic preference would vary considerably among surveyed providers without a clear majority, as would the rationale behind those preferences. METHODS Email invitations were sent to members of the Society of Cardiovascular Anesthesiologists, who were asked to identify the anesthetics or sedatives they typically prefer to administer during induction, prebypass, bypass, postbypass, and postoperative periods and why they prefer those agents. Members' beliefs regarding the importance of anesthetics on postoperative outcomes were also assessed. RESULTS Invitations were sent on 2 separate dates to 3328 and 3274 members, of whom 689 (21%) responded. The median (interquartile range [IQR]) respondent age was 45 (37-56) years, 79% were men, and 75% were fellowship trained. The most frequently chosen drug for induction was propofol (80%). Isoflurane was the most frequently selected primary agent for the prebypass (57%), bypass (62%), and postbypass periods (50%). Sevoflurane was the second most frequently selected (30%; 17%, and 24%, respectively). Propofol was the third most frequently selected agent for the bypass (14%) and postbypass periods (17%). Ease of use was the most frequently selected reason for administering isoflurane and sevoflurane for each period. During bypass, the second most frequently selected rationale for using isoflurane and sevoflurane was institutional practice. A total of 76% responded that the perfusionist typically delivers the bypass anesthetic. Ischemic preconditioning, organ protection, and postoperative cognitive function were infrequently selected as rationales for preferring the volatile anesthetics. Most respondents (73%) think that anesthetics have organ-protective properties, especially isoflurane (74%) and sevoflurane (59%), and 72% believed that anesthetic choice contributes to patient outcome. The median (IQR) agreement (0 = strongly disagree to 100 = strongly agree) was 72 (63-85) for the statement that "inhaled anesthetics are an optimal maintenance anesthetic for cardiac surgery." CONCLUSIONS In a survey of cardiac anesthesiologists, a majority of respondents indicated that they prefer volatile anesthetics for maintenance of anesthesia, that anesthetic selection impacts patient outcomes, and that volatile anesthetics have organ-protective properties. The members' rationales for preferring these agents possibly reflect that practical considerations, such as ease of use, effectiveness, and institutional practice, also influence anesthetic selection during cardiac surgery in addition to considerations such as organ protection.
Collapse
Affiliation(s)
- Brian P O'Gara
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Najla Y Beydoun
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Abirami Kumaresan
- Department of Anesthesia, Keck Medical Center, Los Angeles, California
| | - Shahzad Shaefi
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
16
|
Affiliation(s)
- Matthew Anstey
- Sir Charles Gairdner Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
- School of Public Health, Curtin University, Perth, WA, Australia
| | - Shahzad Shaefi
- Harvard Medical School, Harvard University, Boston, MA, United States
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Bradley Wibrow
- Sir Charles Gairdner Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
| |
Collapse
|
17
|
Maben S, Gosling AF, Shaefi S. The Acute Respiratory Distress Syndrome. Crit Care 2022. [DOI: 10.1093/med/9780190885939.003.0004] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Acute respiratory distress syndrome (ARDS) defines a clinical entity involving respiratory failure, hypoxemia, and bilateral pulmonary infiltrates on chest X-ray secondary to noncardiogenic pulmonary edema. Pathogenesis requires an initial insult that triggers a systemic inflammatory response, ultimately damaging lung parenchyma. Management is multifaceted, including treatment of the underlying disease process, lung-protective ventilation strategies, methods to prevent patient–ventilator dysynchrony, and strategies to improve ventilator:perfusion matching. Escalation to extracorporeal membrane oxygenation may even be required. Several therapies have not been shown to reduce mortality, including inhaled nitric oxide and high-frequency oscillatory ventilation. The mortality rate is high, and recovery is prolonged. There are many significant areas of ongoing research to better delineate patient, disease, and treatment-related factors that reduce morbidity and mortality in ARDS.
Collapse
|
18
|
Glaser AC, Kanter JH, Martinez-Camblor P, Taenzer A, Anderson MV, Buhl L, Shaefi S, Pannu A, Boone MD. The Effect of Antiseizure Medication Administration on Mortality and Early Posttraumatic Seizures in Critically Ill Older Adults with Traumatic Brain Injury. Neurocrit Care 2022; 37:538-546. [PMID: 35641806 DOI: 10.1007/s12028-022-01531-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of morbidity and mortality in the United States. Older adults represent an understudied and growing TBI population. Current Brain Trauma Foundation guidelines support prophylactic antiseizure medication (ASM) administration to reduce the risk of early posttraumatic seizures (within 7 days of injury) in patients with severe TBI. Whether ASM decreases mortality or early seizure risk in this population remains unclear. This study addresses the knowledge gap regarding the impact of ASM administration on the risk of seizure or mortality after TBI in patients more than 65 years of age. METHODS This retrospective cohort study used a publicly available data set from the Medical Information Mart for Intensive Care-III from the Massachusetts Institute of Technology. Our cohort included patients 65 years or older with a primary exposure of early ASM administration with TBI resulting in an intensive care unit (ICU) admission in a level I trauma center from 2001 to 2012. A double-robust inverse propensity scale weighted model on the basis of proportional hazard and logistic regression models was created to assess the association between ASM administration and risk of death within 7 days of admission to the ICU. Secondary outcomes included 30-day mortality and 1-year mortality, early posttraumatic seizures, ICU length of stay, and hospital length of stay. RESULTS Of 1145 patients 65 years or older with TBI admitted to an ICU, 783 (68.4%) received ASM within the first 24 h. Patients meeting inclusion criteria were predominantly white (83.8%) and were male (52.3%), with a median (interquartile range) age of 81 (74-86) years. TBI severity, classified by Glasgow Coma Score, was predominantly mild (71.2%), followed by moderate (16.8%) and severe (11.3%). Patients who received ASM were less likely to have died at 7 days (adjusted death hazard ratio [HR] = 0.48 [95% confidence interval {CI} 0.28-0.88], P = 0.005), at 30 days (adjusted HR 0.67 [95% CI 0.45-0.99], P = 0.045), and at 1 year (adjusted HR 0.72 [95% CI 0.54-0.97], P = 0.029). Groups were not different in regard to seizure (adjusted seizure odds ratio 1.18 [95% CI 0.61-2.26]) compared with those who did not receive ASM. CONCLUSIONS Early ASM administration was associated with reduced mortality at 7 days, 30 days, and 1 year but did not decrease the risk of early seizures among older adults who presented with TBI at an ICU. This benefit was observed in mild, moderate, and severe TBI assessed by Glasgow Coma Score on presentation among patients 65 years old and older and suggests broader recommendations for the use of ASM in older adults who present with TBI of any severity at an ICU.
Collapse
Affiliation(s)
- Adam C Glaser
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH, USA
| | - John H Kanter
- Section of Neurosurgery, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA.,Department of Biomedical Data Sciences, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH, USA
| | - Andreas Taenzer
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA.,Department of Pediatrics, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA
| | - Matt V Anderson
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA
| | - Lauren Buhl
- Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Ameeka Pannu
- Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Myles D Boone
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA.,Department of Neurology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| |
Collapse
|
19
|
O'Gara BP, Shaefi S, Gasangwa DV, Patxot M, Beydoun N, Mueller AL, Sagy I, Novack V, Banner-Goodspeed VM, Kumaresan A, Shapeton A, Spear K, Bose S, Baedorf-Kassis EN, Gosling AF, Mahmood FUD, Khabbaz K, Subramaniam B, Talmor DS. Anesthetics to Prevent Lung Injury in Cardiac Surgery: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2022; 36:3747-3757. [DOI: 10.1053/j.jvca.2022.04.018] [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] [Received: 10/14/2021] [Revised: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 11/11/2022]
|
20
|
Barrett CD, Moore HB, Moore EE, Benjamin Christie D, Orfanos S, Anez‐Bustillos L, Jhunjhunwala R, Hussain S, Shaefi S, Wang J, Hajizadeh N, Baedorf‐Kassis EN, Al‐Shammaa A, Capers K, Banner‐Goodspeed V, Wright FL, Bull T, Moore PK, Nemec H, Thomas Buchanan J, Nonnemacher C, Rajcooar N, Ramdeo R, Yacoub M, Guevara A, Espinal A, Hattar L, Moraco A, McIntyre R, Talmor DS, Sauaia A, Yaffe MB. MUlticenter STudy of tissue plasminogen activator (alteplase) use in COVID‐19 severe respiratory failure (MUST COVID): A retrospective cohort study. Res Pract Thromb Haemost 2022; 6:e12669. [PMID: 35341072 PMCID: PMC8935535 DOI: 10.1002/rth2.12669] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/28/2021] [Accepted: 01/16/2022] [Indexed: 01/08/2023] Open
Abstract
Background Few therapies exist to treat severe COVID‐19 respiratory failure once it develops. Given known diffuse pulmonary microthrombi on autopsy studies of COVID‐19 patients, we hypothesized that tissue plasminogen activator (tPA) may improve pulmonary function in COVID‐19 respiratory failure. Methods A multicenter, retrospective, observational study of patients with confirmed COVID‐19 and severe respiratory failure who received systemic tPA (alteplase) was performed. Seventy‐nine adults from seven medical centers were included in the final analysis after institutional review boards' approval; 23 were excluded from analysis because tPA was administered for pulmonary macroembolism or deep venous thrombosis. The primary outcome was improvement in the PaO2/FiO2 ratio from baseline to 48 h after tPA. Linear mixed modeling was used for analysis. Results tPA was associated with significant PaO2/FiO2 improvement at 48 h (estimated paired difference = 23.1 ± 6.7), which was sustained at 72 h (interaction term p < 0.00). tPA administration was also associated with improved National Early Warning Score 2 scores at 24, 48, and 72 h after receiving tPA (interaction term p = 0.00). D‐dimer was significantly elevated immediately after tPA, consistent with lysis of formed clot. Patients with declining respiratory status preceding tPA administration had more marked improvement in PaO2/FiO2 ratios than those who had poor but stable (not declining) respiratory status. There was one intracranial hemorrhage, which occurred within 24 h following tPA administration. Conclusions These data suggest tPA is associated with significant improvement in pulmonary function in severe COVID‐19 respiratory failure, especially in patients whose pulmonary function is in decline, and has an acceptable safety profile in this patient population.
Collapse
|
21
|
Nunez JI, Gosling AF, O'Gara B, Kennedy KF, Rycus P, Abrams D, Brodie D, Shaefi S, Garan AR, Grandin EW. Correction to: Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis. Intensive Care Med 2022; 48:644-645. [PMID: 35041017 DOI: 10.1007/s00134-021-06605-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jose I Nunez
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andre F Gosling
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Brian O'Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kevin F Kennedy
- Smith Center for Cardiology Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - Darryl Abrams
- Division of Pulmonary and Critical Care Medicine, Columbia Presbyterian Medical Center, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Columbia Presbyterian Medical Center, New York, NY, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A Reshad Garan
- Division of Cardiovascular Medicine, Section of Advanced Heart Failure, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, DE-319, Boston, MA, 02215, USA
| | - E Wilson Grandin
- Smith Center for Cardiology Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA. .,Division of Cardiovascular Medicine, Section of Advanced Heart Failure, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, DE-319, Boston, MA, 02215, USA.
| |
Collapse
|
22
|
Calhoun A, Pannu A, Mueller AL, Elmadhoun O, Valencia JD, Krajewski ML, O'Gara BP, Katsiampoura A, O'Connor ST, Chu L, Monteith E, Shankar P, Spear K, Shaefi S. Intraoperative Oxygen Practices in Cardiac Surgery - A National Survey. J Cardiothorac Vasc Anesth 2022; 36:2917-2926. [DOI: 10.1053/j.jvca.2022.01.019] [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] [Received: 11/12/2021] [Revised: 01/05/2022] [Accepted: 01/14/2022] [Indexed: 11/11/2022]
|
23
|
Nunez JI, Gosling AF, O'Gara B, Kennedy KF, Rycus P, Abrams D, Brodie D, Shaefi S, Garan AR, Grandin EW. Bleeding and thrombotic events in adults supported with venovenous extracorporeal membrane oxygenation: an ELSO registry analysis. Intensive Care Med 2021; 48:213-224. [PMID: 34921625 DOI: 10.1007/s00134-021-06593-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 11/24/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE This study aimed at analyzing the prevalence, mortality association, and risk factors for bleeding and thrombosis events (BTEs) among adults supported with venovenous extracorporeal membrane oxygenation (VV-ECMO). METHODS We queried the Extracorporeal Life Support Organization registry for adults supported with VV-ECMO from 2010 to 2017. Multivariable logistic regression modeling was used to assess the association between BTEs and in-hospital mortality and the predictors of BTEs. RESULTS Among 7579 VV-ECMO patients meeting criteria, 40.2% experienced ≥ 1 BTE. Thrombotic events comprised 54.9% of all BTEs and were predominantly ECMO circuit thrombosis. BTE rates decreased significantly over the study period (p < 0.001). The inpatient mortality rate was 34.9%. Bleeding events (1.69 [1.49-1.93]) were more strongly associated with in-hospital mortality than thrombotic events (1.23 [1.08-1.41]) p < 0.01 for both. The BTEs most strongly associated with mortality were ischemic stroke (4.50 [2.55-7.97]) and medical bleeding, including intracranial (5.71 [4.02-8.09]), pulmonary (2.02 [1.54-2.67]), and gastrointestinal (1.54 [1.2-1.98]) hemorrhage, all p < 0.01. Risk factors for bleeding included acute kidney injury and pre-ECMO vasopressor support and for thrombosis were higher weight, multisite cannulation, pre-ECMO arrest, and higher PaCO2 at ECMO initiation. Longer time on ECMO, younger age, higher pH, and earlier year of support were associated with bleeding and thrombosis. CONCLUSIONS Although decreasing over time, BTEs remain common during VV-ECMO and have a strong, cumulative association with in-hospital mortality. Thrombotic events are more frequent, but bleeding carries a higher risk of inpatient mortality. Differential risk factors for bleeding and thrombotic complications exist, raising the possibility of a tailored approach to VV-ECMO management.
Collapse
Affiliation(s)
- Jose I Nunez
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andre F Gosling
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Brian O'Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kevin F Kennedy
- Smith Center for Cardiology Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - Darryl Abrams
- Division of Pulmonary and Critical Care Medicine, Columbia Presbyterian Medical Center, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Columbia Presbyterian Medical Center, New York, NY, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - A Reshad Garan
- Division of Cardiovascular Medicine, Section of Advanced Heart Failure, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, DE-319, Boston, MA, 02215, USA
| | - E Wilson Grandin
- Smith Center for Cardiology Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA. .,Division of Cardiovascular Medicine, Section of Advanced Heart Failure, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, DE-319, Boston, MA, 02215, USA.
| |
Collapse
|
24
|
Douin DJ, Shaefi S, Brenner SK, Gupta S, Park I, Wright FL, Mathews KS, Chan L, Al-Samkari H, Orfanos S, Radbel J, Leaf DE. Tissue Plasminogen Activator in Critically Ill Adults with COVID-19. Ann Am Thorac Soc 2021; 18:1917-1921. [PMID: 33872546 PMCID: PMC8641829 DOI: 10.1513/annalsats.202102-127rl] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- David J. Douin
- University of Colorado School of MedicineAurora, Colorado
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical CenterBoston, Massachusetts
| | | | - Shruti Gupta
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
| | - Isabel Park
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
| | | | | | - Lili Chan
- Icahn School of Medicine at Mount SinaiNew York, New York
| | | | - Sarah Orfanos
- Rutgers Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey
| | - Jared Radbel
- Rutgers Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey
| | - David E. Leaf
- Brigham and Women’s Hospital, Harvard Medical SchoolBoston, Massachusetts
| |
Collapse
|
25
|
Wang N, Vuerich M, Kalbasi A, Graham JJ, Csizmadia E, Manickas-Hill ZJ, Woolley A, David C, Miller EM, Gorman K, Hecht JL, Shaefi S, Robson SC, Longhi MS. Limited TCR repertoire and ENTPD1 dysregulation mark late-stage COVID-19. iScience 2021; 24:103205. [PMID: 34608452 PMCID: PMC8482538 DOI: 10.1016/j.isci.2021.103205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/06/2021] [Accepted: 09/28/2021] [Indexed: 01/12/2023] Open
Abstract
T cell exhaustion and dysfunction are hallmarks of severe COVID-19. To gain insights into the pathways underlying these alterations, we performed a comprehensive transcriptome analysis of peripheral-blood-mononuclear-cells (PBMCs), spleen, lung, kidney, liver, and heart obtained at autopsy from COVID-19 patients and matched controls, using the nCounter CAR-T-Characterization panel. We found substantial gene alterations in COVID-19-impacted organs, especially the lung where altered TCR repertoires are noted. Reduced TCR repertoires are also observed in PBMCs of severe COVID-19 patients. ENTPD1/CD39, an ectoenzyme defining exhausted T-cells, is upregulated in the lung, liver, spleen, and PBMCs of severe COVID-19 patients where expression positively correlates with markers of vasculopathy. Heightened ENTPD1/CD39 is paralleled by elevations in STAT-3 and HIF-1α transcription factors; and by markedly reduced CD39-antisense-RNA, a long-noncoding-RNA negatively regulating ENTPD1/CD39 at the post-transcriptional level. Limited TCR repertoire and aberrant regulation of ENTPD1/CD39 could have permissive roles in COVID-19 progression and indicate potential therapeutic targets to reverse disease. Transcriptome profiling of COVID-19 autoptic tissue and PBMC was carried out There is limited TCR repertoire in lung, kidney and PBMC of severe COVID-19 cases There are increased CD39 levels in PBMC of severe COVID-19 patients High HIF-1a and STAT-3 and low CD39-antisense might be linked with CD39 increase
Collapse
Affiliation(s)
- Na Wang
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, Shandong 250021, China.,School of Medicine, Shandong University, 44 Wenhuaxilu, Jinan, Shandong 250021, China
| | - Marta Vuerich
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Ahmadreza Kalbasi
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Jonathon J Graham
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Eva Csizmadia
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | | | - Ann Woolley
- Division of Infectious Diseases, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Clement David
- NanoString Technologies, 530 Fairview Avenue N, Seattle, WA 98109, USA
| | - Eric M Miller
- NanoString Technologies, 530 Fairview Avenue N, Seattle, WA 98109, USA
| | - Kara Gorman
- NanoString Technologies, 530 Fairview Avenue N, Seattle, WA 98109, USA
| | - Jonathan L Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Simon C Robson
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.,Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Maria Serena Longhi
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| |
Collapse
|
26
|
Barrett CD, Moore HB, Moore EE, Wang DJ, Hajizadeh N, Biffl WL, Lottenberg L, Patel PR, Truitt MS, McIntyre R, Bull TM, Ammons LA, Ghasabyan A, Chandler J, Douglas I, Schmidt E, Moore PK, Wright FL, Ramdeo R, Borrego R, Rueda M, Dhupa A, McCaul DS, Dandan T, Sarkar PK, Khan B, Sreevidya C, McDaniel C, Grossman Verner HM, Pearcy C, Anez-Bustillos L, Baedorf-Kassis EN, Jhunjhunwala R, Shaefi S, Capers K, Banner-Goodspeed V, Talmor DS, Sauaia A, Yaffe MB. Study of Alteplase for Respiratory Failure in SARS-CoV-2 COVID-19: A Vanguard Multicenter, Rapidly Adaptive, Pragmatic, Randomized Controlled Trial. Chest 2021; 161:710-727. [PMID: 34592318 PMCID: PMC8474873 DOI: 10.1016/j.chest.2021.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/31/2021] [Accepted: 09/20/2021] [Indexed: 12/30/2022] Open
Abstract
Background Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. Research Question Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? Study Design and Methods Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao2 to Fio2 ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao2 to Fio2 ratio improvement of > 50% or Pao2 to Fio2 ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. Results Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao2 to Fio2 ratio values were significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the percent change of Pao2 to Fio2 ratio at 48 h (16.9% control [interquartile range (IQR), –8.3% to 36.8%] vs 29.8% tPA bolus [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. Interpretation The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. Trial Registry ClinicalTrials.gov; No.: NCT04357730; URL: www.clinicaltrials.gov
Collapse
Affiliation(s)
- Christopher D Barrett
- Department of Surgery, Boston University School of Medicine, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Departments of Biological Engineering and Biology, Massachusetts Institute of Technology, Cambridge, MA
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO; Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO.
| | - D Janice Wang
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Negin Hajizadeh
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Department of Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - Lawrence Lottenberg
- Department of Surgery, St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL
| | - Purvesh R Patel
- Department of Medicine, Baylor College of Medicine, Houston, Dallas, TX
| | - Michael S Truitt
- Department of Surgery, Methodist Dallas Medical Center, Dallas, TX
| | - Robert McIntyre
- Department of Surgery, University of Colorado Denver, Aurora, CO
| | - Todd M Bull
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Lee Anne Ammons
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO
| | - Arsen Ghasabyan
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO
| | - James Chandler
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO
| | - Ivor Douglas
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO
| | - Eric Schmidt
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO
| | - Peter K Moore
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Denver, Aurora, CO
| | | | - Ramona Ramdeo
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Robert Borrego
- Department of Surgery, St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL
| | - Mario Rueda
- Department of Surgery, St. Mary's Medical Center, Florida Atlantic University, West Palm Beach, FL
| | - Achal Dhupa
- Division of Trauma/Acute Care Surgery, Department of Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - D Scott McCaul
- Division of Trauma/Acute Care Surgery, Department of Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - Tala Dandan
- Division of Trauma/Acute Care Surgery, Department of Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA
| | - Pralay K Sarkar
- Department of Medicine, Baylor College of Medicine, Houston, Dallas, TX
| | - Benazir Khan
- Department of Medicine, Baylor College of Medicine, Houston, Dallas, TX
| | | | - Conner McDaniel
- Department of Surgery, Methodist Dallas Medical Center, Dallas, TX
| | | | | | - Lorenzo Anez-Bustillos
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elias N Baedorf-Kassis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Rashi Jhunjhunwala
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Krystal Capers
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Angela Sauaia
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO; Colorado School of Public Health and Department of Surgery, University of Colorado Denver, Denver, CO
| | - Michael B Yaffe
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Departments of Biological Engineering and Biology, Massachusetts Institute of Technology, Cambridge, MA.
| |
Collapse
|
27
|
Rhee J, Kuznetsov A, McKay T, Lyons M, Houstis N, Mekkonen J, Ethridge B, Ibala R, Hahm E, Gitlin J, Guseh JS, Kitchen R, Rosenzweig A, Shaefi S, Flaczyk A, Qu J, Akeju O. Serum Proteomics of Older Patients Undergoing Major Cardiac Surgery: Identification of Biomarkers Associated With Postoperative Delirium. Front Aging Neurosci 2021; 13:699763. [PMID: 34456709 PMCID: PMC8386117 DOI: 10.3389/fnagi.2021.699763] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/18/2021] [Indexed: 11/28/2022] Open
Abstract
Background Postoperative delirium (POD) is an acute altered mental state commonly encountered after cardiac surgery. The pathophysiological mechanisms underlying POD remain unclear. We aimed to identify circulating proteins significantly altered after major cardiac surgery with cardiopulmonary bypass (CPB). We also aimed to enable inferences on associations with POD. Methods Serum and whole blood samples were collected before CPB (n = 16 patients; n = 8 with POD) and again from the same patients on postoperative day 1. All patients were clinically evaluated for POD on postoperative days 1–3. An aptamer-based proteomics platform (SOMAscan) was used to quantify serum protein abundance in patients with POD compared with non-POD controls. We also performed a lipopolysaccharide (LPS)-based in vitro functional analysis (TruCulture) on whole blood samples from patients with POD and non-POD controls to approximate surgical stress. Cytokine levels were determined using a Luminex immunoassay. Results Cardiac surgery with CPB resulted in a significant (padj < 0.01) change in 48.8% (637 out of 1,305) of proteins detected by SOMAscan. Gene set enrichment showed that the most impacted biological processes involved myeloid cell activation. Specifically, activation and degranulation of neutrophils were the top five highest-scoring processes. Pathway analyses with the Kyoto Encyclopedia of Genes and Genomes (KEGG) showed that metabolic enzymes, particularly those of glycolysis, were elevated in serum concentration after surgery. Several proteins were significantly increased postoperatively in patients diagnosed with POD relative to the non-POD controls, with interleukin-6 (IL-6) showing the greatest fold-change. LPS stimulation of whole blood samples confirmed these findings. Linear regression analysis showed a highly significant correlation between Confusion Assessment Method (CAM) scores and CPB-mediated changes in cGMP-inhibited 3′,5′-cyclic phosphodiesterase A (PDE3A). Conclusions Cardiac surgery with CPB resulted in inflammasome changes accompanied by unexpected increases in metabolic pathways. In exploratory analyses, we found that POD was associated with changes in the expression level of various proteins, most notably IL-6 and PDE3A. This study and ongoing protein biomarker studies will likely help quantify risk or confirm the diagnosis for POD and increase understanding of its pathophysiological mechanisms.
Collapse
Affiliation(s)
- James Rhee
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alexandra Kuznetsov
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Tina McKay
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Margaret Lyons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Nicholas Houstis
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jennifer Mekkonen
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Breanna Ethridge
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Reine Ibala
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Eunice Hahm
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jacob Gitlin
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - J Sawalla Guseh
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Robert Kitchen
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Anthony Rosenzweig
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Adam Flaczyk
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jason Qu
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
28
|
Rhee J, Kuznetsov A, McKay T, Lyons M, Houstis N, Mekkonen J, Ethridge B, Ibala R, Hahm E, Gitlin J, Guseh JS, Kitchen R, Rosenzweig A, Shaefi S, Flaczyk A, Qu J, Akeju O. Serum Proteomics of Older Patients Undergoing Major Cardiac Surgery: Identification of Biomarkers Associated With Postoperative Delirium. Front Aging Neurosci 2021; 13:699763. [PMID: 34456709 DOI: 10.3389/fnagi.2021.699763pmid-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/18/2021] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is an acute altered mental state commonly encountered after cardiac surgery. The pathophysiological mechanisms underlying POD remain unclear. We aimed to identify circulating proteins significantly altered after major cardiac surgery with cardiopulmonary bypass (CPB). We also aimed to enable inferences on associations with POD. METHODS Serum and whole blood samples were collected before CPB (n = 16 patients; n = 8 with POD) and again from the same patients on postoperative day 1. All patients were clinically evaluated for POD on postoperative days 1-3. An aptamer-based proteomics platform (SOMAscan) was used to quantify serum protein abundance in patients with POD compared with non-POD controls. We also performed a lipopolysaccharide (LPS)-based in vitro functional analysis (TruCulture) on whole blood samples from patients with POD and non-POD controls to approximate surgical stress. Cytokine levels were determined using a Luminex immunoassay. RESULTS Cardiac surgery with CPB resulted in a significant (padj < 0.01) change in 48.8% (637 out of 1,305) of proteins detected by SOMAscan. Gene set enrichment showed that the most impacted biological processes involved myeloid cell activation. Specifically, activation and degranulation of neutrophils were the top five highest-scoring processes. Pathway analyses with the Kyoto Encyclopedia of Genes and Genomes (KEGG) showed that metabolic enzymes, particularly those of glycolysis, were elevated in serum concentration after surgery. Several proteins were significantly increased postoperatively in patients diagnosed with POD relative to the non-POD controls, with interleukin-6 (IL-6) showing the greatest fold-change. LPS stimulation of whole blood samples confirmed these findings. Linear regression analysis showed a highly significant correlation between Confusion Assessment Method (CAM) scores and CPB-mediated changes in cGMP-inhibited 3',5'-cyclic phosphodiesterase A (PDE3A). CONCLUSIONS Cardiac surgery with CPB resulted in inflammasome changes accompanied by unexpected increases in metabolic pathways. In exploratory analyses, we found that POD was associated with changes in the expression level of various proteins, most notably IL-6 and PDE3A. This study and ongoing protein biomarker studies will likely help quantify risk or confirm the diagnosis for POD and increase understanding of its pathophysiological mechanisms.
Collapse
Affiliation(s)
- James Rhee
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alexandra Kuznetsov
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Tina McKay
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Margaret Lyons
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Nicholas Houstis
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jennifer Mekkonen
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Breanna Ethridge
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Reine Ibala
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Eunice Hahm
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jacob Gitlin
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - J Sawalla Guseh
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Robert Kitchen
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Anthony Rosenzweig
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Adam Flaczyk
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Jason Qu
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Oluwaseun Akeju
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
29
|
Churpek MM, Gupta S, Spicer AB, Hayek SS, Srivastava A, Chan L, Melamed ML, Brenner SK, Radbel J, Madhani-Lovely F, Bhatraju PK, Bansal A, Green A, Goyal N, Shaefi S, Parikh CR, Semler MW, Leaf DE. Machine Learning Prediction of Death in Critically Ill Patients With Coronavirus Disease 2019. Crit Care Explor 2021; 3:e0515. [PMID: 34476402 PMCID: PMC8378790 DOI: 10.1097/cce.0000000000000515] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Critically ill patients with coronavirus disease 2019 have variable mortality. Risk scores could improve care and be used for prognostic enrichment in trials. We aimed to compare machine learning algorithms and develop a simple tool for predicting 28-day mortality in ICU patients with coronavirus disease 2019. DESIGN This was an observational study of adult patients with coronavirus disease 2019. The primary outcome was 28-day inhospital mortality. Machine learning models and a simple tool were derived using variables from the first 48 hours of ICU admission and validated externally in independent sites and temporally with more recent admissions. Models were compared with a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 using the area under the receiver operating characteristic curve and calibration. SETTING Sixty-eight U.S. ICUs. PATIENTS Adults with coronavirus disease 2019 admitted to 68 ICUs in the United States between March 4, 2020, and June 29, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The study included 5,075 patients, 1,846 (36.4%) of whom died by day 28. eXtreme Gradient Boosting had the highest area under the receiver operating characteristic curve in external validation (0.81) and was well-calibrated, while k-nearest neighbors were the lowest performing machine learning algorithm (area under the receiver operating characteristic curve 0.69). Findings were similar with temporal validation. The simple tool, which was created using the most important features from the eXtreme Gradient Boosting model, had a significantly higher area under the receiver operating characteristic curve in external validation (0.78) than the Sequential Organ Failure Assessment score (0.69), National Early Warning Score (0.60), and CURB-65 (0.65; p < 0.05 for all comparisons). Age, number of ICU beds, creatinine, lactate, arterial pH, and Pao2/Fio2 ratio were the most important predictors in the eXtreme Gradient Boosting model. CONCLUSIONS eXtreme Gradient Boosting had the highest discrimination overall, and our simple tool had higher discrimination than a modified Sequential Organ Failure Assessment score, National Early Warning Score, and CURB-65 on external validation. These models could be used to improve triage decisions and clinical trial enrichment.
Collapse
Affiliation(s)
- Matthew M Churpek
- Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin, Madison, WI
| | - Shruti Gupta
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexandra B Spicer
- Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin, Madison, WI
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Department of Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michal L Melamed
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine, Seton Hall, NJ
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, NJ
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Pavan K Bhatraju
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Anip Bansal
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus Aurora, CO
| | - Adam Green
- Department of Critical Care Medicine, Cooper University Health Care, Camden, NJ
| | - Nitender Goyal
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Chirag R Parikh
- Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - David E Leaf
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
30
|
Longhi MS, Wang N, Kalbasi A, Vuerich M, Manickas-Hill ZJ, Hecht J, Shaefi S, Robson SC. Aberrant CD39 levels and regulation mark COVID-19 late stage. The Journal of Immunology 2021. [DOI: 10.4049/jimmunol.206.supp.62.02] [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] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Abstract
Previous studies have reported immune cell exhaustion and perturbed T-cell immunity in novel-coronavirus-disease-19 (COVID-19). Heightened levels of CD39, an ectonucleotidase key to immunoregulation, are detected in CD4 and CD8 T-cells during viral infection where they correlate with worse disease outcome.
We performed a comprehensive transcriptome analysis of T-cell related gene pathways in PBMCs from 18 COVID-19 patients (6 convalescent, 6 with moderate disease and 6 with severe disease) and 6 healthy controls (HC); and in formalin-fixed autoptic tissue, obtained from the spleen, lung, kidney, liver and heart of 5 COVID-19 cases and 2 controls. Analysis was performed using nCounter CAR-T characterization panel (NanoString).
Our data show that in COVID-19 tissues there is a marked decrease in TCR diversity that is also present in PBMCs of severe patients, when compared with patients with moderate disease, convalescents and HC. A similar pattern is also noted when analyzing PBMCs for TCR signaling, Th1, Th17 and Treg-related transcripts. Heightened CD39 transcripts are detected in lung, liver and spleen of COVID-19 patients as well as in PBMCs obtained from patients with severe disease. A similar trend is observed for STAT-3, and HIF-1alpha, transcription factors that regulate CD39. Notably, CD39-AS RNA, a lncRNA that regulates CD39 at the post-transcriptional level, is markedly reduced in severe COVID-19 patients.
In conclusion, our data indicate systemic and local alterations in T-cell immunity in COVID-19. Aberrantly high levels of CD39 and related transcription factors and concomitant decreases in CD39-AS RNA in the late stage of disease suggest a role for CD39 and purinergic signaling in COVID-19 progression.
Collapse
Affiliation(s)
| | - Na Wang
- 1Beth Israel Deaconess Med. Ctr., Harvard Med. Sch
| | | | | | | | | | | | | |
Collapse
|
31
|
Short SAP, Gupta S, Brenner SK, Hayek SS, Srivastava A, Shaefi S, Singh H, Wu B, Bagchi A, Al-Samkari H, Dy R, Wilkinson K, Zakai NA, Leaf DE. d-dimer and Death in Critically Ill Patients With Coronavirus Disease 2019. Crit Care Med 2021; 49:e500-e511. [PMID: 33591017 PMCID: PMC8275993 DOI: 10.1097/ccm.0000000000004917] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Hypercoagulability may be a key mechanism for acute organ injury and death in patients with severe coronavirus disease 2019, but the relationship between elevated plasma levels of d-dimer, a biomarker of coagulation activation, and mortality has not been rigorously studied. We examined the independent association between d-dimer and death in critically ill patients with coronavirus disease 2019. DESIGN Multicenter cohort study. SETTING ICUs at 68 hospitals across the United States. PATIENTS Critically ill adults with coronavirus disease 2019 admitted to ICUs between March 4, 2020, and May 25, 2020, with a measured d-dimer concentration on ICU day 1 or 2. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary exposure was the highest normalized d-dimer level (assessed in four categories: < 2×, 2-3.9×, 4-7.9×, and ≥ 8× the upper limit of normal) on ICU day 1 or 2. The primary endpoint was 28-day mortality. Multivariable logistic regression was used to adjust for confounders. Among 3,418 patients (63.1% male; median age 62 yr [interquartile range, 52-71 yr]), 3,352 (93.6%) had a d-dimer concentration above the upper limit of normal. A total of 1,180 patients (34.5%) died within 28 days. Patients in the highest compared with lowest d-dimer category had a 3.11-fold higher odds of death (95% CI, 2.56-3.77) in univariate analyses, decreasing to a 1.81-fold increased odds of death (95% CI, 1.43-2.28) after multivariable adjustment for demographics, comorbidities, and illness severity. Further adjustment for therapeutic anticoagulation did not meaningfully attenuate this relationship (odds ratio, 1.73; 95% CI, 1.36-2.19). CONCLUSIONS In a large multicenter cohort study of critically ill patients with coronavirus disease 2019, higher d-dimer levels were independently associated with a greater risk of death.
Collapse
Affiliation(s)
- Samuel A P Short
- Larner College of Medicine, University of Vermont, Burlington, VT
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, NJ
- Department of Internal Medicine, Heart & Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, NJ
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Benjamin Wu
- Division of Pulmonary, Critical Care & Sleep Medicine, NYU Langone Medical Center, New York, NY
| | - Aranya Bagchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, MA
| | - Rajany Dy
- Department of Medicine, University Medical Center of Southern Nevada Hospital, University of Nevada, Las Vegas, NV
| | - Katherine Wilkinson
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - Neil A Zakai
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
32
|
Al-Samkari H, Gupta S, Leaf RK, Wang W, Rosovsky RP, Brenner SK, Hayek SS, Berlin H, Kapoor R, Shaefi S, Melamed ML, Sutherland A, Radbel J, Green A, Garibaldi BT, Srivastava A, Leonberg-Yoo A, Shehata AM, Flythe JE, Rashidi A, Goyal N, Chan L, Mathews KS, Hedayati SS, Dy R, Toth-Manikowski SM, Zhang J, Mallappallil M, Redfern RE, Bansal AD, Short SAP, Vangel MG, Admon AJ, Semler MW, Bauer KA, Hernán MA, Leaf DE. Thrombosis, Bleeding, and the Observational Effect of Early Therapeutic Anticoagulation on Survival in Critically Ill Patients With COVID-19. Ann Intern Med 2021; 174:622-632. [PMID: 33493012 PMCID: PMC7863679 DOI: 10.7326/m20-6739] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [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: 11/22/2022] Open
Abstract
BACKGROUND Hypercoagulability may be a key mechanism of death in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE To evaluate the incidence of venous thromboembolism (VTE) and major bleeding in critically ill patients with COVID-19 and examine the observational effect of early therapeutic anticoagulation on survival. DESIGN In a multicenter cohort study of 3239 critically ill adults with COVID-19, the incidence of VTE and major bleeding within 14 days after intensive care unit (ICU) admission was evaluated. A target trial emulation in which patients were categorized according to receipt or no receipt of therapeutic anticoagulation in the first 2 days of ICU admission was done to examine the observational effect of early therapeutic anticoagulation on survival. A Cox model with inverse probability weighting to adjust for confounding was used. SETTING 67 hospitals in the United States. PARTICIPANTS Adults with COVID-19 admitted to a participating ICU. MEASUREMENTS Time to death, censored at hospital discharge, or date of last follow-up. RESULTS Among the 3239 patients included, the median age was 61 years (interquartile range, 53 to 71 years), and 2088 (64.5%) were men. A total of 204 patients (6.3%) developed VTE, and 90 patients (2.8%) developed a major bleeding event. Independent predictors of VTE were male sex and higher D-dimer level on ICU admission. Among the 2809 patients included in the target trial emulation, 384 (11.9%) received early therapeutic anticoagulation. In the primary analysis, during a median follow-up of 27 days, patients who received early therapeutic anticoagulation had a similar risk for death as those who did not (hazard ratio, 1.12 [95% CI, 0.92 to 1.35]). LIMITATION Observational design. CONCLUSION Among critically ill adults with COVID-19, early therapeutic anticoagulation did not affect survival in the target trial emulation. PRIMARY FUNDING SOURCE None.
Collapse
Affiliation(s)
- Hanny Al-Samkari
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Shruti Gupta
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.G., D.E.L.)
| | - Rebecca Karp Leaf
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Wei Wang
- Brigham and Women's Hospital, Boston, Massachusetts (W.W.)
| | - Rachel P Rosovsky
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A., R.K.L., R.P.R.)
| | - Samantha K Brenner
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, New Jersey (S.K.B.)
| | - Salim S Hayek
- University of Michigan Medical Center, Ann Arbor, Michigan (S.S.H., H.B.)
| | - Hanna Berlin
- University of Michigan Medical Center, Ann Arbor, Michigan (S.S.H., H.B.)
| | - Rajat Kapoor
- Indiana University School of Medicine, Indianapolis, Indiana (R.K.)
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (S.S.)
| | - Michal L Melamed
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York (M.L.M.)
| | - Anne Sutherland
- Rutgers New Jersey Medical School, Newark, New Jersey (A.S.)
| | - Jared Radbel
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.R.)
| | - Adam Green
- Cooper University Health Care, Camden, New Jersey (A.G.)
| | | | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, and Northwestern University Feinberg School of Medicine, Chicago, Illinois (A.S.)
| | - Amanda Leonberg-Yoo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.L.)
| | - Alexandre M Shehata
- Hackensack Meridian Health Mountainside Medical Center, Glen Ridge, New Jersey (A.M.S.)
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, UNC School of Medicine, and Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina (J.E.F.)
| | - Arash Rashidi
- University Hospitals Cleveland Medical Center, Cleveland, Ohio (A.R.)
| | | | - Lili Chan
- Icahn School of Medicine at Mount Sinai, New York, New York (L.C., K.S.M.)
| | - Kusum S Mathews
- Icahn School of Medicine at Mount Sinai, New York, New York (L.C., K.S.M.)
| | - S Susan Hedayati
- University of Texas Southwestern Medical Center, Dallas, Texas (S.S.H.)
| | - Rajany Dy
- University Medical Center of Southern Nevada Hospital, University of Nevada, Las Vegas, Nevada (R.D.)
| | | | - Jingjing Zhang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania (J.Z.)
| | - Mary Mallappallil
- Kings County Hospital Center, New York City Health and Hospital Corporation, Brooklyn, New York (M.M.)
| | - Roberta E Redfern
- ProMedica Research, ProMedica Toledo Hospital, Toledo, Ohio (R.E.R.)
| | - Amar D Bansal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (A.D.B.)
| | - Samuel A P Short
- University of Vermont Larner College of Medicine, Burlington, Vermont (S.A.S.)
| | - Mark G Vangel
- Massachusetts General Hospital Biostatistics Center, Boston, Massachusetts (M.G.V.)
| | | | - Matthew W Semler
- Vanderbilt University Medical Center, Nashville, Tennessee (M.W.S.)
| | - Kenneth A Bauer
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts (K.A.B.)
| | - Miguel A Hernán
- Harvard T.H. Chan School of Public Health and Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts (M.A.H.)
| | - David E Leaf
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (S.G., D.E.L.)
| |
Collapse
|
33
|
Shaefi S, Shankar P, Mueller AL, O'Gara BP, Spear K, Khabbaz KR, Bagchi A, Chu LM, Banner-Goodspeed V, Leaf DE, Talmor DS, Marcantonio ER, Subramaniam B. Intraoperative Oxygen Concentration and Neurocognition after Cardiac Surgery. Anesthesiology 2021; 134:189-201. [PMID: 33331902 PMCID: PMC7855826 DOI: 10.1097/aln.0000000000003650] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite evidence suggesting detrimental effects of perioperative hyperoxia, hyperoxygenation remains commonplace in cardiac surgery. Hyperoxygenation may increase oxidative damage and neuronal injury leading to potential differences in postoperative neurocognition. Therefore, this study tested the primary hypothesis that intraoperative normoxia, as compared to hyperoxia, reduces postoperative cognitive dysfunction in older patients having cardiac surgery. METHODS A randomized double-blind trial was conducted in patients aged 65 yr or older having coronary artery bypass graft surgery with cardiopulmonary bypass. A total of 100 patients were randomized to one of two intraoperative oxygen delivery strategies. Normoxic patients (n = 50) received a minimum fraction of inspired oxygen of 0.35 to maintain a Pao2 above 70 mmHg before and after cardiopulmonary bypass and between 100 and 150 mmHg during cardiopulmonary bypass. Hyperoxic patients (n = 50) received a fraction of inspired oxygen of 1.0 throughout surgery, irrespective of Pao2 levels. The primary outcome was neurocognitive function measured on postoperative day 2 using the Telephonic Montreal Cognitive Assessment. Secondary outcomes included neurocognitive function at 1, 3, and 6 months, as well as postoperative delirium, mortality, and durations of mechanical ventilation, intensive care unit stay, and hospital stay. RESULTS The median age was 71 yr (interquartile range, 68 to 75), and the median baseline neurocognitive score was 17 (16 to 19). The median intraoperative Pao2 was 309 (285 to 352) mmHg in the hyperoxia group and 153 (133 to 168) mmHg in the normoxia group (P < 0.001). The median Telephonic Montreal Cognitive Assessment score on postoperative day 2 was 18 (16 to 20) in the hyperoxia group and 18 (14 to 20) in the normoxia group (P = 0.42). Neurocognitive function at 1, 3, and 6 months, as well as secondary outcomes, were not statistically different between groups. CONCLUSIONS In this randomized controlled trial, intraoperative normoxia did not reduce postoperative cognitive dysfunction when compared to intraoperative hyperoxia in older patients having cardiac surgery. Although the optimal intraoperative oxygenation strategy remains uncertain, the results indicate that intraoperative hyperoxia does not worsen postoperative cognition after cardiac surgery. EDITOR’S PERSPECTIVE
Collapse
|
34
|
Gupta S, Wang W, Hayek SS, Chan L, Mathews KS, Melamed ML, Brenner SK, Leonberg-Yoo A, Schenck EJ, Radbel J, Reiser J, Bansal A, Srivastava A, Zhou Y, Finkel D, Green A, Mallappallil M, Faugno AJ, Zhang J, Velez JCQ, Shaefi S, Parikh CR, Charytan DM, Athavale AM, Friedman AN, Redfern RE, Short SAP, Correa S, Pokharel KK, Admon AJ, Donnelly JP, Gershengorn HB, Douin DJ, Semler MW, Hernán MA, Leaf DE. Association Between Early Treatment With Tocilizumab and Mortality Among Critically Ill Patients With COVID-19. JAMA Intern Med 2021; 181:41-51. [PMID: 33080002 PMCID: PMC7577201 DOI: 10.1001/jamainternmed.2020.6252] [Citation(s) in RCA: 313] [Impact Index Per Article: 104.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Therapies that improve survival in critically ill patients with coronavirus disease 2019 (COVID-19) are needed. Tocilizumab, a monoclonal antibody against the interleukin 6 receptor, may counteract the inflammatory cytokine release syndrome in patients with severe COVID-19 illness. OBJECTIVE To test whether tocilizumab decreases mortality in this population. DESIGN, SETTING, AND PARTICIPANTS The data for this study were derived from a multicenter cohort study of 4485 adults with COVID-19 admitted to participating intensive care units (ICUs) at 68 hospitals across the US from March 4 to May 10, 2020. Critically ill adults with COVID-19 were categorized according to whether they received or did not receive tocilizumab in the first 2 days of admission to the ICU. Data were collected retrospectively until June 12, 2020. A Cox regression model with inverse probability weighting was used to adjust for confounding. EXPOSURES Treatment with tocilizumab in the first 2 days of ICU admission. MAIN OUTCOMES AND MEASURES Time to death, compared via hazard ratios (HRs), and 30-day mortality, compared via risk differences. RESULTS Among the 3924 patients included in the analysis (2464 male [62.8%]; median age, 62 [interquartile range {IQR}, 52-71] years), 433 (11.0%) received tocilizumab in the first 2 days of ICU admission. Patients treated with tocilizumab were younger (median age, 58 [IQR, 48-65] vs 63 [IQR, 52-72] years) and had a higher prevalence of hypoxemia on ICU admission (205 of 433 [47.3%] vs 1322 of 3491 [37.9%] with mechanical ventilation and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of <200 mm Hg) than patients not treated with tocilizumab. After applying inverse probability weighting, baseline and severity-of-illness characteristics were well balanced between groups. A total of 1544 patients (39.3%) died, including 125 (28.9%) treated with tocilizumab and 1419 (40.6%) not treated with tocilizumab. In the primary analysis, during a median follow-up of 27 (IQR, 14-37) days, patients treated with tocilizumab had a lower risk of death compared with those not treated with tocilizumab (HR, 0.71; 95% CI, 0.56-0.92). The estimated 30-day mortality was 27.5% (95% CI, 21.2%-33.8%) in the tocilizumab-treated patients and 37.1% (95% CI, 35.5%-38.7%) in the non-tocilizumab-treated patients (risk difference, 9.6%; 95% CI, 3.1%-16.0%). CONCLUSIONS AND RELEVANCE Among critically ill patients with COVID-19 in this cohort study, the risk of in-hospital mortality in this study was lower in patients treated with tocilizumab in the first 2 days of ICU admission compared with patients whose treatment did not include early use of tocilizumab. However, the findings may be susceptible to unmeasured confounding, and further research from randomized clinical trials is needed.
Collapse
Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Wei Wang
- Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michal L Melamed
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey.,Department of Internal Medicine, Hackensack Meridian Health, Hackensack University Medical Center, Hackensack, New Jersey
| | - Amanda Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Edward J Schenck
- Divison of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine Center, New York, New York
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus Aurora, Aurora
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yan Zhou
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Diana Finkel
- Department of Medicine, Division of Infectious Diseases, New Jersey Medical School, Rutgers University, Newark
| | - Adam Green
- Division of Critical Care, Cooper University Health Care, Camden, New Jersey
| | - Mary Mallappallil
- Division of Nephrology, Kings County Hospital Center, New York City Health and Hospital Corporation, Brooklyn, New York
| | - Anthony J Faugno
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Jingjing Zhang
- Division of Nephrology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Juan Carlos Q Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland, Brisbane, Australia
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David M Charytan
- Division of Nephrology, Department of Medicine, NYU (New York University) Langone Medical Center, New York, New York
| | | | - Allon N Friedman
- Department of Medicine, Indiana University School of Medicine/Indiana University Health, Indianapolis
| | | | | | - Simon Correa
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kapil K Pokharel
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor.,Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Miguel A Hernán
- Department of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Harvard-MIT (Massachusetts Institute of Technology) Program in Health Sciences and Technology, Boston, Massachusetts
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | |
Collapse
|
35
|
Teja B, Alibhai N, Rubenfeld GD, Taggart LR, Jivraj N, Hirji SA, O’Gara BP, Shaefi S. Prevalence of Clostridioides difficile Infection in Critically Ill Patients with Extreme Leukocytosis and Diarrhea. Infect Dis Rep 2021; 13:18-22. [PMID: 33401377 PMCID: PMC7839043 DOI: 10.3390/idr13010003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/21/2020] [Revised: 11/27/2020] [Accepted: 12/11/2020] [Indexed: 01/28/2023] Open
Abstract
While early empiric antibiotic therapy is beneficial for patients presenting with sepsis, the presentation of sepsis from Clostridioides difficile (formerly Clostridium difficile) infection (CDI) has not been well studied in large cohorts. We sought to determine whether the combination of extreme leukocytosis and diarrhea was strongly predictive of CDI in a cohort of 8659 patients admitted to the intensive care unit. We found that CDI was present in 15.0% (95% CI, 12.1–18.3%) of patients with extreme leukocytosis and diarrhea and that mortality for those with CDI, diarrhea, and extreme leukocytosis was 33.8% (95% CI, 23.2–44.3%). These data support consideration of empiric treatment for CDI in unstable critically ill patients with extreme leukocytosis and diarrhea, along with treatment of other possible sources of sepsis as appropriate. Empiric treatment for CDI can usually be discontinued promptly, along with narrowing of other broad-spectrum antimicrobial coverage, if a sensitive C. difficile test is negative.
Collapse
Affiliation(s)
- Bijan Teja
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON M5B 1T8, Canada; (G.D.R.); (N.J.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
- Correspondence:
| | - Nafeesa Alibhai
- Honors Integrated Sciences, University of British Columbia, Vancouver, BC V6T 1Z2, Canada;
| | - Gordon D. Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON M5B 1T8, Canada; (G.D.R.); (N.J.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Linda R. Taggart
- Division of Infectious Diseases, Department of Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada;
| | - Naheed Jivraj
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON M5B 1T8, Canada; (G.D.R.); (N.J.)
| | - Sameer A. Hirji
- Department of General Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Brian P. O’Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (B.P.O.); (S.S.)
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (B.P.O.); (S.S.)
| |
Collapse
|
36
|
Abstract
Interventional pulmonology is a dynamic and evolving field in respiratory medicine. Advances have improved the ability to diagnose and manage diseases of the airways. A shift toward early detection of malignant disease has generated a focus on innovative diagnostic techniques. With patient populations living longer with malignant and benign diseases, the role for interventional bronchoscopy has grown. In cancer groups, novel immunotherapies have improved the prospects of clinical outcomes and reignited a focus on optimizing patient performance status to enable access to anticancer therapy. This review discusses current and emerging diagnostic modalities and therapeutic approaches available to manage airway diseases.
Collapse
Affiliation(s)
- Hardeep S Kalsi
- Division of Medicine, Lungs for Living Research Centre, UCL Respiratory, University College London, Rayne Building, 5 University Street, London, UK
| | - Ricky Thakrar
- Division of Medicine, Lungs for Living Research Centre, UCL Respiratory, University College London, Rayne Building, 5 University Street, London, UK
| | - Andre F Gosling
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA, USA
| | - Neal Navani
- Division of Medicine, Lungs for Living Research Centre, UCL Respiratory, University College London, Rayne Building, 5 University Street, London, UK.
| |
Collapse
|
37
|
Murugappan KR, Walsh DP, Mittel A, Sontag D, Shaefi S. Veno-venous extracorporeal membrane oxygenation allocation in the COVID-19 pandemic. J Crit Care 2020; 61:221-226. [PMID: 33220575 PMCID: PMC7664357 DOI: 10.1016/j.jcrc.2020.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/17/2020] [Accepted: 11/07/2020] [Indexed: 01/08/2023]
Abstract
Rapid global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resultant clinical illness, coronavirus disease 2019 (COVID-19), drove the World Health Organization to declare COVID-19 a pandemic. Veno-venous Extra-Corporeal Membrane Oxygenation (VV-ECMO) is an established therapy for management of patients demonstrating the most severe forms of hypoxemic respiratory failure from COVID-19. However, features of COVID-19 pathophysiology and necessary length of treatment present distinct challenges for utilization of VV-ECMO within the current healthcare emergency. In addition, growing allocation concerns due to capacity and cost present significant challenges. Ethical and legal aspects pertinent to triage of this resource-intensive, but potentially life-saving, therapy in the setting of the COVID-19 pandemic are reviewed here. Given considerations relevant to VV-ECMO use, additional emphasis has been placed on emerging hospital resource scarcity and disproportionate representation of healthcare workers among the ill. Considerations are also discussed surrounding withdrawal of VV-ECMO and the role for early communication as well as consultation from palliative care teams and local ethics committees. In discussing how to best manage these issues in the COVID-19 pandemic at present, we identify gaps in the literature and policy important to clinicians as this crisis continues. VV-ECMO may successfully treat respiratory failure due to COVID-19. The coronavirus pandemic necessitates judicious use of this resource-intensive therapy. Unique features of COVID-19, including isolation from surrogates, present challenges. Providers face difficult triage decisions that must be communicated appropriately. We review available resources and support tools for clinicians considering VV-ECMO.
Collapse
Affiliation(s)
- Kadhiresan R Murugappan
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States of America.
| | - Daniel P Walsh
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States of America
| | - Aaron Mittel
- Department of Anesthesiology, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, United States of America
| | - David Sontag
- Managing General Counsel, Beth Israel Lahey Health, 109 Brookline Ave, Suite 300, Boston, MA 02215, United States of America; Ethics Advisory Committee, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, United States of America
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, United States of America
| |
Collapse
|
38
|
Molnar MZ, Bhalla A, Azhar A, Tsujita M, Talwar M, Balaraman V, Sodhi A, Kadaria D, Eason JD, Hayek SS, Coca SG, Shaefi S, Neyra JA, Gupta S, Leaf DE, Kovesdy CP. Outcomes of critically ill solid organ transplant patients with COVID-19 in the United States. Am J Transplant 2020; 20:3061-3071. [PMID: 32844546 PMCID: PMC7460925 DOI: 10.1111/ajt.16280] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/11/2020] [Accepted: 08/17/2020] [Indexed: 01/25/2023]
Abstract
National data on patient characteristics, treatment, and outcomes of critically ill coronavirus disease 2019 (COVID-19) solid organ transplant (SOT) patients are limited. We analyzed data from a multicenter cohort study of adults with laboratory-confirmed COVID-19 admitted to intensive care units (ICUs) at 68 hospitals across the United States from March 4 to May 8, 2020. From 4153 patients, we created a propensity score matched cohort of 386 patients, including 98 SOT patients and 288 non-SOT patients. We used a binomial generalized linear model (log-binomial model) to examine the association of SOT status with death and other clinical outcomes. Among the 386 patients, the median age was 60 years, 72% were male, and 41% were black. Death within 28 days of ICU admission was similar in SOT and non-SOT patients (40% and 43%, respectively; relative risk [RR] 0.92; 95% confidence interval [CI]: 0.70-1.22). Other outcomes and requirement for organ support including receipt of mechanical ventilation, development of acute respiratory distress syndrome, and receipt of vasopressors were also similar between groups. There was a trend toward higher risk of acute kidney injury requiring renal replacement therapy in SOT vs. non-SOT patients (37% vs. 27%; RR [95% CI]: 1.34 [0.97-1.85]). Death and organ support requirement were similar between SOT and non-SOT critically ill patients with COVID-19.
Collapse
Affiliation(s)
- Miklos Z. Molnar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA,Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA,Correspondence Miklos Z. Molnar
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Ambreen Azhar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Makoto Tsujita
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Amik Sodhi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Dipen Kadaria
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - James D. Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, Tennessee, USA,Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Salim S. Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven G. Coca
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Javier A. Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Csaba P. Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA,Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| | | |
Collapse
|
39
|
Gupta S, Hayek SS, Wang W, Chan L, Mathews KS, Melamed ML, Brenner SK, Leonberg-Yoo A, Schenck EJ, Radbel J, Reiser J, Bansal A, Srivastava A, Zhou Y, Sutherland A, Green A, Shehata AM, Goyal N, Vijayan A, Velez JCQ, Shaefi S, Parikh CR, Arunthamakun J, Athavale AM, Friedman AN, Short SAP, Kibbelaar ZA, Abu Omar S, Admon AJ, Donnelly JP, Gershengorn HB, Hernán MA, Semler MW, Leaf DE. Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US. JAMA Intern Med 2020; 180:1436-1447. [PMID: 32667668 PMCID: PMC7364338 DOI: 10.1001/jamainternmed.2020.3596] [Citation(s) in RCA: 608] [Impact Index Per Article: 152.0] [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: 05/19/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
Abstract
Importance The US is currently an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, yet few national data are available on patient characteristics, treatment, and outcomes of critical illness from COVID-19. Objectives To assess factors associated with death and to examine interhospital variation in treatment and outcomes for patients with COVID-19. Design, Setting, and Participants This multicenter cohort study assessed 2215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the US from March 4 to April 4, 2020. Exposures Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including number of ICU beds. Main Outcomes and Measures The primary outcome was 28-day in-hospital mortality. Multilevel logistic regression was used to evaluate factors associated with death and to examine interhospital variation in treatment and outcomes. Results A total of 2215 patients (mean [SD] age, 60.5 [14.5] years; 1436 [64.8%] male; 1738 [78.5%] with at least 1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 784 patients (35.4%) had died, 824 (37.2%) were discharged, and 607 (27.4%) remained hospitalized. At the end of study follow-up (median, 16 days; interquartile range, 8-28 days), 875 patients (39.5%) had died, 1203 (54.3%) were discharged, and 137 (6.2%) remained hospitalized. Factors independently associated with death included older age (≥80 vs <40 years of age: odds ratio [OR], 11.15; 95% CI, 6.19-20.06), male sex (OR, 1.50; 95% CI, 1.19-1.90), higher body mass index (≥40 vs <25: OR, 1.51; 95% CI, 1.01-2.25), coronary artery disease (OR, 1.47; 95% CI, 1.07-2.02), active cancer (OR, 2.15; 95% CI, 1.35-3.43), and the presence of hypoxemia (Pao2:Fio2<100 vs ≥300 mm Hg: OR, 2.94; 95% CI, 2.11-4.08), liver dysfunction (liver Sequential Organ Failure Assessment score of 2-4 vs 0: OR, 2.61; 95% CI, 1.30-5.25), and kidney dysfunction (renal Sequential Organ Failure Assessment score of 4 vs 0: OR, 2.43; 95% CI, 1.46-4.05) at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs ≥100 ICU beds: OR, 3.28; 95% CI, 2.16-4.99). Hospitals varied considerably in the risk-adjusted proportion of patients who died (range, 6.6%-80.8%) and in the percentage of patients who received hydroxychloroquine, tocilizumab, and other treatments and supportive therapies. Conclusions and Relevance This study identified demographic, clinical, and hospital-level risk factors that may be associated with death in critically ill patients with COVID-19 and can facilitate the identification of medications and supportive therapies to improve outcomes.
Collapse
Affiliation(s)
- Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Salim S. Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Wei Wang
- Department of Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kusum S. Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michal L. Melamed
- Montefiore Medical Center, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Samantha K. Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, New Jersey
- Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, New Jersey
| | - Amanda Leonberg-Yoo
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Edward J. Schenck
- Divison of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jared Radbel
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine
| | - Yan Zhou
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Anne Sutherland
- Division of Pulmonary and Critical Care Medicine, Rutgers New Jersey Medical School, Newark
| | - Adam Green
- Cooper University Health Care, Camden, New Jersey
| | - Alexandre M. Shehata
- Department of Medicine, Hackensack Meridian Health Mountainside Medical Center, Glen Ridge, New Jersey
| | - Nitender Goyal
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Anitha Vijayan
- Division of Nephrology, Washington University in St Louis, St Louis, Missouri
| | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health System, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Chirag R. Parikh
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Justin Arunthamakun
- Division of Cardiology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | | | - Allon N. Friedman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | | | | | - Samah Abu Omar
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew J. Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
| | - John P. Donnelly
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor
| | - Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Miguel A. Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard–Massachusetts Institute of Technology Division of Health Sciences and Technology, Boston, Massachusetts
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
40
|
Hayek SS, Brenner SK, Azam TU, Shadid HR, Anderson E, Berlin H, Pan M, Meloche C, Feroz R, O'Hayer P, Kaakati R, Bitar A, Padalia K, Perry D, Blakely P, Gupta S, Shaefi S, Srivastava A, Charytan DM, Bansal A, Mallappallil M, Melamed ML, Shehata AM, Sunderram J, Mathews KS, Sutherland AK, Nallamothu BK, Leaf DE. In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study. BMJ 2020; 371:m3513. [PMID: 32998872 PMCID: PMC7525342 DOI: 10.1136/bmj.m3513] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [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: 12/24/2022]
Abstract
OBJECTIVES To estimate the incidence, risk factors, and outcomes associated with in-hospital cardiac arrest and cardiopulmonary resuscitation in critically ill adults with coronavirus disease 2019 (covid-19). DESIGN Multicenter cohort study. SETTING Intensive care units at 68 geographically diverse hospitals across the United States. PARTICIPANTS Critically ill adults (age ≥18 years) with laboratory confirmed covid-19. MAIN OUTCOME MEASURES In-hospital cardiac arrest within 14 days of admission to an intensive care unit and in-hospital mortality. RESULTS Among 5019 critically ill patients with covid-19, 14.0% (701/5019) had in-hospital cardiac arrest, 57.1% (400/701) of whom received cardiopulmonary resuscitation. Patients who had in-hospital cardiac arrest were older (mean age 63 (standard deviation 14) v 60 (15) years), had more comorbidities, and were more likely to be admitted to a hospital with a smaller number of intensive care unit beds compared with those who did not have in-hospital cardiac arrest. Patients who received cardiopulmonary resuscitation were younger than those who did not (mean age 61 (standard deviation 14) v 67 (14) years). The most common rhythms at the time of cardiopulmonary resuscitation were pulseless electrical activity (49.8%, 199/400) and asystole (23.8%, 95/400). 48 of the 400 patients (12.0%) who received cardiopulmonary resuscitation survived to hospital discharge, and only 7.0% (28/400) survived to hospital discharge with normal or mildly impaired neurological status. Survival to hospital discharge differed by age, with 21.2% (11/52) of patients younger than 45 years surviving compared with 2.9% (1/34) of those aged 80 or older. CONCLUSIONS Cardiac arrest is common in critically ill patients with covid-19 and is associated with poor survival, particularly among older patients.
Collapse
Affiliation(s)
- Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, NJ, USA
- Department of Internal Medicine, Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, NJ, USA
| | - Tariq U Azam
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Husam R Shadid
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth Anderson
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hanna Berlin
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael Pan
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Chelsea Meloche
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rafey Feroz
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Patrick O'Hayer
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rayan Kaakati
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Abbas Bitar
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kishan Padalia
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Perry
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Pennelope Blakely
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David M Charytan
- Division of Nephrology, New York University Grossman School of Medicine, New York, NY, USA
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Mary Mallappallil
- Division of Nephrology, Department of Internal Medicine, NYC Health + Hospitals Kings County Hospital Center, Brooklyn, NY, USA
| | - Michal L Melamed
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | | | - Jag Sunderram
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne K Sutherland
- Division of Pulmonary and Critical Care Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Brahmajee K Nallamothu
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
41
|
Santer P, Anstey MH, Patrocínio MD, Wibrow B, Teja B, Shay D, Shaefi S, Parsons CS, Houle TT, Eikermann M. Effect of midodrine versus placebo on time to vasopressor discontinuation in patients with persistent hypotension in the intensive care unit (MIDAS): an international randomised clinical trial. Intensive Care Med 2020; 46:1884-1893. [PMID: 32885276 DOI: 10.1007/s00134-020-06216-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/12/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE ICU discharge is often delayed by a requirement for intravenous vasopressor medications to maintain normotension. We hypothesised that the administration of midodrine, an oral α1-adrenergic agonist, as adjunct to standard treatment shortens the duration of intravenous vasopressor requirement. METHODS In this multicentre, randomised, controlled trial including three tertiary referral hospitals in the US and Australia, we enrolled adult patients with hypotension requiring a single-agent intravenous vasopressor for ≥ 24 h. Subjects received oral midodrine (20 mg) or placebo every 8 h in addition to standard care until cessation of intravenous vasopressors, ICU discharge, or occurrence of adverse events. The primary outcome was time to vasopressor discontinuation. Secondary outcomes included time to ICU discharge readiness, ICU and hospital lengths of stay, and ICU readmission rates. RESULTS Between October 2012 and June 2019, 136 participants were randomised, of whom 132 received the allocated intervention and were included in the analysis (modified intention-to-treat approach). Time to vasopressor discontinuation was not different between midodrine and placebo groups (median [IQR], 23.5 [10-54] vs 22.5 [10.4-40] h; difference, 1 h; 95% CI - 10.4 to 12.3 h; p = 0.62). No differences in secondary endpoints were observed. Bradycardia occurred more often after midodrine administration (5 [7.6%] vs 0 [0%], p = 0.02). CONCLUSION Midodrine did not accelerate liberation from intravenous vasopressors and was not effective for the treatment of hypotension in critically ill patients.
Collapse
Affiliation(s)
- Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Matthew H Anstey
- Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia
| | - Maria D Patrocínio
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Bradley Wibrow
- Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia
| | - Bijan Teja
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Charles S Parsons
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA. .,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
| | | |
Collapse
|
42
|
Gosling AF, Bose, S, Gomez E, Parikh, M, Cook C, Sarge T, Shaefi S, Leibowitz A. Perioperative Considerations for Tracheostomies in the Era of COVID-19. Anesth Analg 2020; 131:378-386. [PMID: 32459668 PMCID: PMC7273938 DOI: 10.1213/ane.0000000000005009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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] [Accepted: 05/21/2020] [Indexed: 01/06/2023]
Abstract
The morbidity, mortality, and blistering pace of transmission of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented worldwide health crisis. Coronavirus disease 2019 (COVID-19), the disease produced by SARS-CoV-2 infection, is remarkable for persistent, severe respiratory failure requiring mechanical ventilation that places considerable strain on critical care resources. Because recovery from COVID-19-associated respiratory failure can be prolonged, tracheostomy may facilitate patient management and optimize the use of mechanical ventilators. Several important considerations apply to plan tracheostomies for COVID-19-infected patients. After performing a literature review of tracheostomies during the severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks, we synthesized important learning points from these experiences and suggested an approach for perioperative teams involved in these procedures during the COVID-19 pandemic. Multidisciplinary teams should be involved in decisions regarding timing and appropriateness of the procedure. As the theoretical risk of disease transmission is increased during aerosol-generating procedures (AGPs), stringent infectious precautions are warranted. Personal protective equipment (PPE) should be available and worn by all personnel present during tracheostomy. The number of people in the room should be limited to those absolutely necessary. Using the most experienced available operators will minimize the total time that staff is exposed to an infectious aerosolized environment. An approach that secures the airway in the safest and quickest manner will minimize the time any part of the airway is open to the environment. Deep neuromuscular blockade (train-of-four ratio = 0) will facilitate surgical exposure and prevent aerosolization due to patient movement or coughing. For percutaneous tracheostomies, the bronchoscopist should be able to reintubate if needed. Closed-loop communication must occur at all times among members of the team. If possible, after tracheostomy is performed, waiting until the patient is virus-free before changing the cannula or downsizing may reduce the chances of health care worker infection. Tracheostomies in COVID-19 patients present themselves as extremely high risk for all members of the procedural team. To mitigate risk, systematic meticulous planning of each procedural step is warranted along with strict adherence to local/institutional protocols.
Collapse
Affiliation(s)
- Andre F. Gosling
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Somnath Bose,
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Ernest Gomez
- Department of Surgery, Division of Otolaryngology/Head and Neck Surgery
| | - Mihir Parikh,
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine
- Department of Surgery, Chest Disease Center
| | - Charles Cook
- Division of Acute Care Surgery, Trauma and Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Todd Sarge
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Shahzad Shaefi
- From the Department of Anesthesia, Critical Care and Pain Medicine
| | - Akiva Leibowitz
- From the Department of Anesthesia, Critical Care and Pain Medicine
| |
Collapse
|
43
|
Abstract
IMPORTANCE Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures. OBJECTIVE To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020. EXPOSURES PND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission. MAIN OUTCOMES AND MEASURES The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure. RESULTS A total of 2 380 473 patients (mean [SD] age, 75.36 (7.31) years; 1 336 736 [56.1%] women) who underwent surgical procedures were included, of whom 44 974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2 142 157 patients [90.0%]), presenting for orthopedic surgery (1 523 782 patients [64.0%]) in urban medical centers (2 179 893 patients [91.6%]) that were private nonprofits (1 798 749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P < .001), were less likely to be discharged home (9947 patients [22.1%] vs 914 925 patients [39.2%]; P < .001), and had a higher incidence of mortality at 1 year after treatment (4580 patients [10.2%] vs 103 767 patients [4.4%]; P < .001). After adjusting for patient and hospital characteristics, the presence of a PND within 1 year of the index procedure was associated with an increase of $17 275 (95% CI, $17 058-$17 491) in cost in the 1-year postadmission period (P < .001). CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that among older Medicare patients undergoing surgical treatment, a diagnosis of a PND was associated with an increase in health care costs for up to 1 year following the surgical procedure. Given the magnitude of this cost burden, PNDs represent an appealing target for risk mitigation and improvement in value-based health care.
Collapse
Affiliation(s)
- M. Dustin Boone
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Brian Sites
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Ariel Mueller
- Department of Anesthesia, Harvard Medical School, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Andreas H. Taenzer
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Shahzad Shaefi
- Department of Anesthesia, Harvard Medical School, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
44
|
Abstract
Traditional approaches to clinical risk assessment utilize age as a marker of increased vulnerability to stress. Relatively recent advancements in the study of aging have led to the concept of the frailty syndrome, which represents a multidimensional state of depleted physiologic and psychosocial reserve and clinical vulnerability that is related to but variably present with advancing age. The frailty syndrome is now a well-established clinical entity that serves as both a guide for clinical intervention and a predictor of poor outcomes in the primary and acute care settings. The biological aspects of the syndrome broadly represent a network of interrelated perturbations involving the age-related accumulation of molecular, cellular, and tissue damage that leads to multisystem dysregulation, functional decline, and disproportionately poor response to physiologic stress. Given the complexity of the underlying biologic processes, several well-validated approaches to define frailty clinically have been developed, each with distinct and reasonable considerations. Stemming from this background, the past several years have seen a number of observational studies conducted in intensive care units that have established that the determination of frailty is both feasible and prognostically useful in the critical care setting. Specifically, frailty as determined by several different frailty measurement tools appears associated with mortality, increased health care utilization, and disability, and has the potential to improve risk stratification of intensive care patients. While substantial variability in the implementation of frailty measurement likely limits the generalizability of specific findings, the overall prognostic trends may offer some assistance in guiding management decisions with patients and their families. Although no trials have assessed interventions to improve the outcomes of critically ill older people living with frailty, the particular vulnerability of this population offers a promising target for intervention in the future.
Collapse
Affiliation(s)
- Justin C De Biasio
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aaron M Mittel
- Department of Anesthesiology, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Ariel L Mueller
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Shahzad Shaefi
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
45
|
Esmaeeli S, Hrdlicka CM, Bastos AB, Wang J, Gomez-Paz S, Hanafy KA, Lioutas VA, Ogilvy CS, Thomas AJ, Shaefi S, Fehnel CR, Nozari A. Robotically assisted transcranial Doppler with artificial intelligence for assessment of cerebral vasospasm after subarachnoid hemorrhage. J Neurocrit Care 2020. [DOI: 10.18700/jnc.200002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|
46
|
Cahill LA, Guo F, Nguyen J, Zhang F, Seshadri A, Keegan J, Hauser CJ, Otterbein LE, Robson S, Shaefi S, Yaffe MB, Lederer JA. Circulating Factors in Trauma Plasma Activate Specific Human Immune Cell Subsets. Injury 2020; 51:819-829. [PMID: 32171537 PMCID: PMC7441590 DOI: 10.1016/j.injury.2020.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/24/2020] [Accepted: 03/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trauma causes tissue injury that results in the release of damage associated molecular patterns (DAMPs) and other mediators at the site of injury and systemically. Such mediators disrupt immune system homeostasis and may activate multicellular immune responses with downstream complications such as the development of infections and sepsis. To characterize these alterations, we used time-of-flight mass cytometry to determine how trauma plasma affects normal peripheral blood mononuclear cell (PBMC) activation to gain insights into the kinetics and nature of trauma-induced circulating factors on human immune cell populations. A better understanding of the components that activate cells in trauma may aid in the discovery of therapeutic targets. METHODS PBMCs from healthy volunteers were cultured with 5% plasma (healthy, trauma-1day, or trauma-3day) or known DAMPs for 24 h. Samples were stained with a broad immunophenotyping CyTOF antibody panel. Multiplex (Luminex) cytokine assays were used to measure differences in multiple cytokine levels in healthy and trauma plasma samples. RESULTS Plasma from day 1, but not day 3 trauma patients induced the acute expansion of CD11c+ NK cells and CD73+/CCR7+ CD8 T cell subpopulations. Additionally, trauma plasma did not induce CD4+ T cell expansion but did cause a phenotypic shift towards CD38+/CCR7+ expressing CD4+ T cells. Multiplex analysis of cytokines by Luminex showed increased levels of IL-1RA, IL-6 and IL-15 in trauma-1day plasma. Similar to trauma day 1 plasma, PBMC stimulation with known DAMPs showed activation and expansion of CD11c+ NK cells. CONCLUSIONS We hypothesized that circulating factors in trauma plasma would induce phenotypic activation of normal human immune cell subsets. Using an unbiased approach, we identified specific changes in immune cell subsets that respond to trauma plasma. Additionally, CD11c+ NK cells expanded in response to DAMPs and LPS, suggesting they may also be responding to similar components in trauma plasma. Collectively, our data demonstrate that the normal PBMC response to trauma plasma involves marked changes in specific subsets of NK and CD8+ T cell populations. Future studies will target the function of these trauma plasma reactive immune cell subsets. These findings have important implications for the field of acute traumatic injuries.
Collapse
Affiliation(s)
- Laura A Cahill
- Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, United States.
| | - Fei Guo
- Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, United States.
| | - Jennifer Nguyen
- Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, United States.
| | - Fan Zhang
- Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, United States.
| | - Anupamaa Seshadri
- Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, United States.
| | - Joshua Keegan
- Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, United States.
| | - Carl J Hauser
- Beth Israel Deaconess Medical Centre, Boston, MA, United States.
| | - Leo E Otterbein
- Beth Israel Deaconess Medical Centre, Boston, MA, United States.
| | - Simon Robson
- Beth Israel Deaconess Medical Centre, Boston, MA, United States.
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical Centre, Boston, MA, United States.
| | - Michael B Yaffe
- Beth Israel Deaconess Medical Centre, Boston, MA, United States.
| | - James A Lederer
- Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, United States.
| |
Collapse
|
47
|
O’Gara BP, Mueller A, Gasangwa DVI, Patxot M, Shaefi S, Khabbaz K, Banner-Goodspeed V, Pascal-Leone A, Marcantonio ER, Subramaniam B. Prevention of Early Postoperative Decline: A Randomized, Controlled Feasibility Trial of Perioperative Cognitive Training. Anesth Analg 2020; 130:586-595. [PMID: 31569161 PMCID: PMC7154961 DOI: 10.1213/ane.0000000000004469] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [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: 12/19/2022]
Abstract
BACKGROUND Postoperative delirium and postoperative cognitive dysfunction (POCD) are common after cardiac surgery and contribute to an increased risk of postoperative complications, longer length of stay, and increased hospital mortality. Cognitive training (CT) may be able to durably improve cognitive reserve in areas deficient in delirium and POCD and, therefore, may potentially reduce the risk of these conditions. We sought to determine the feasibility and potential efficacy of a perioperative CT program to reduce the incidence of postoperative delirium and POCD in older cardiac surgery patients. METHODS Randomized controlled trial at a single tertiary care center. Participants included 45 older adults age 60-90 undergoing cardiac surgery at least 10 days from enrollment. Participants were randomly assigned in a 1:1 fashion to either perioperative CT via a mobile device or a usual care control. The primary outcome of feasibility was evaluated by enrollment patterns and adherence to protocol. Secondary outcomes of postoperative delirium and POCD were assessed using the Confusion Assessment Method and the Montreal Cognitive Assessment, respectively. Patient satisfaction was assessed via a postoperative survey. RESULTS Sixty-five percent of eligible patients were enrolled. Median (interquartile range [IQR]) adherence (as a percentage of prescribed minutes played) was 39% (20%-68%), 6% (0%-37%), and 19% (0%-56%) for the preoperative, immediate postoperative, and postdischarge periods, respectively. Median (IQR) training times were 245 (136-536), 18 (0-40), and 122 (0-281) minutes for each period, respectively. The incidence of postoperative delirium (CT group 5/20 [25%] versus control 3/20 [15%]; P = .69) and POCD (CT group 53% versus control 37%; P = .33) was not significantly different between groups for either outcome in this limited sample. CT participants reported a high level of agreement (on a scale of 0-100) with statements that the program was easy to use (median [IQR], 87 [75-97]) and enjoyable (85 [79-91]). CT participants agreed significantly more than controls that their memory (median [IQR], 75 [54-82] vs 51 [49-54]; P = .01) and thinking ability (median [IQR], 78 [64-83] vs 50 [41-68]; P = .01) improved as a result of their participation in the study. CONCLUSIONS A CT program designed for use in the preoperative period is an attractive target for future investigations of cognitive prehabilitation in older cardiac surgery patients. Changes in the functionality of the program and enrichment techniques may improve adherence in future trials. Further investigation is necessary to determine the potential efficacy of cognitive prehabilitation to reduce the risk of postoperative delirium and POCD.
Collapse
Affiliation(s)
- Brian P. O’Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Doris Vanessa I. Gasangwa
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Melissa Patxot
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kamal Khabbaz
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alvaro Pascal-Leone
- Department of Neurology, Division of Cognitive Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Institut Guttman, Universitat Autonoma Barcelona, Bellaterra, Spain
| | - Edward R. Marcantonio
- Department of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
48
|
Evans AS, Weiner MM, Shaefi S, Patel PA, Townsley MM, Kumaresan A, Feinman JW, Fritz AV, Martin AK, Steinberg TB, Renew JR, Gui JL, Radvansky B, Bhatt H, Subramani S, Sharma A, Gutsche JT, Augoustides JG, Ramakrishna H. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019. J Cardiothorac Vasc Anesth 2019; 34:1-11. [PMID: 31759862 DOI: 10.1053/j.jvca.2019.10.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 10/31/2019] [Indexed: 12/26/2022]
Abstract
This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.
Collapse
Affiliation(s)
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative, and Pain Medicine Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine Beth Israel, Deaconess Medical Center, Boston, MA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Abirami Kumaresan
- Department of Anesthesiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA
| | - Ashley V Fritz
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Toby B Steinberg
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Jane L Gui
- Department of Anesthesiology, Perioperative, and Pain Medicine Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brian Radvansky
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA
| | - Himani Bhatt
- Department of Anesthesiology, Perioperative, and Pain Medicine Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Archit Sharma
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, PA.
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
49
|
Abstract
Cellular protective mechanisms exist to ensure survival of the cells and are a fundamental feature of all cells that is necessary for adapting to changes in the environment. Indeed, evolution has ensured that each cell is equipped with multiple overlapping families of genes that safeguard against pathogens, injury, stress, and dysfunctional metabolic processes. Two of the better-known enzymatic systems, conserved through all species, include the heme oxygenases (HO-1/HO-2), and the ectonucleotidases (CD39/73). Each of these systems generates critical bioactive products that regulate the cellular response to a stressor. Absence of these molecules results in the cell being extremely predisposed to collapse and, in most cases, results in the death of the cell. Recent reports have begun to link these two metabolic pathways, and what were once exclusively stand-alone are now being found to be intimately interrelated and do so through their innate ability to generate bioactive products including adenosine, carbon monoxide, and bilirubin. These simple small molecules elicit profound cellular physiologic responses that impact a number of innate immune responses, and participate in the regulation of inflammation and tissue repair. Collectively these enzymes are linked not only because of the mitochondria being the source of their substrates, but perhaps more importantly, because of the impact of their products on specific cellular responses. This review will provide a synopsis of the current state of the field regarding how these systems are linked and how they are now being leveraged as therapeutic modalities in the clinic.
Collapse
Affiliation(s)
- Ghee Rye Lee
- Departments of Surgery and Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Shahzad Shaefi
- Departments of Surgery and Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Leo E Otterbein
- Departments of Surgery and Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| |
Collapse
|
50
|
Lukannek C, Shaefi S, Platzbecker K, Raub D, Santer P, Nabel S, Lecamwasam HS, Houle TT, Eikermann M. The development and validation of the Score for the Prediction of Postoperative Respiratory Complications (SPORC-2) to predict the requirement for early postoperative tracheal re-intubation: a hospital registry study. Anaesthesia 2019; 74:1165-1174. [PMID: 31222727 DOI: 10.1111/anae.14742] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2019] [Indexed: 01/24/2023]
Abstract
Postoperative pulmonary complications are associated with an increase in mortality, morbidity and healthcare utilisation. The Agency for Healthcare Research and Quality recommends risk assessment for postoperative respiratory complications in patients undergoing surgery. In this hospital registry study of adult patients undergoing non-cardiac surgery between 2005 and 2017 at two independent healthcare networks, a prediction instrument for early postoperative tracheal re-intubation was developed and externally validated. This was based on the development of the Score for Prediction Of Postoperative Respiratory Complications. For predictor selection, stepwise backward logistic regression and bootstrap resampling were applied. Development and validation cohorts were represented by 90,893 patients at Partners Healthcare and 67,046 patients at Beth Israel Deaconess Medical Center, of whom 699 (0.8%) and 587 (0.9%) patients, respectively, had their tracheas re-intubated. In addition to five pre-operative predictors identified in the Score for Prediction Of Postoperative Respiratory Complications, the final model included seven additional intra-operative predictors: early post-tracheal intubation desaturation; prolonged duration of surgery; high fraction of inspired oxygen; high vasopressor dose; blood transfusion; the absence of volatile anaesthetic use; and the absence of lung-protective ventilation. The area under the receiver operating characteristic curve for the new score was significantly greater than that of the original Score for Prediction Of Postoperative Respiratory Complications (0.84 [95%CI 0.82-0.85] vs. 0.76 [95%CI 0.75-0.78], respectively; p < 0.001). This may allow clinicians to develop and implement strategies to decrease the risk of early postoperative tracheal re-intubation.
Collapse
Affiliation(s)
- C Lukannek
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - S Shaefi
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - K Platzbecker
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - D Raub
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - P Santer
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - S Nabel
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - H S Lecamwasam
- Department of Anesthesia, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, USA.,Talis Clinical, LLC, USA
| | - T T Houle
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Duisburg-Essen University, Essen, Germany
| |
Collapse
|