1
|
Cruz PD, Wargowsky R, Gonzalez-Almada A, Sifontes EP, Shaykhinurov E, Jaatinen K, Jepson T, Lafleur JE, Yamane D, Perkins J, Pasquale M, Giang B, McHarg M, Falk Z, McCaffrey TA. Blood RNA Biomarkers Identify Bacterial and Biofilm Coinfections in COVID-19 Intensive Care Patients. J Intensive Care Med 2024:8850666241251743. [PMID: 38711289 DOI: 10.1177/08850666241251743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Purpose: Secondary opportunistic coinfections are a significant contributor to morbidity and mortality in intensive care unit (ICU) patients, but can be difficult to identify. Presently, new blood RNA biomarkers were tested in ICU patients to diagnose viral, bacterial, and biofilm coinfections. Methods: COVID-19 ICU patients had whole blood drawn in RNA preservative and stored at -80°C. Controls and subclinical infections were also studied. Droplet digital polymerase chain reaction (ddPCR) quantified 6 RNA biomarkers of host neutrophil activation to bacterial (DEFA1), biofilm (alkaline phosphatase [ALPL], IL8RB/CXCR2), and viral infections (IFI27, RSAD2). Viral titer in blood was measured by ddPCR for SARS-CoV2 (SCV2). Results: RNA biomarkers were elevated in ICU patients relative to controls. DEFA1 and ALPL RNA were significantly higher in severe versus incidental/moderate cases. SOFA score was correlated with white blood cell count (0.42), platelet count (-0.41), creatinine (0.38), and lactate dehydrogenase (0.31). ALPL RNA (0.59) showed the best correlation with SOFA score. IFI27 (0.52) and RSAD2 (0.38) were positively correlated with SCV2 viral titer. Overall, 57.8% of COVID-19 patients had a positive RNA biomarker for bacterial or biofilm infection. Conclusions: RNA biomarkers of host neutrophil activation indicate the presence of bacterial and biofilm coinfections in most COVID-19 patients. Recognizing coinfections may help to guide the treatment of ICU patients.
Collapse
Affiliation(s)
- Philip Dela Cruz
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Richard Wargowsky
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Alberto Gonzalez-Almada
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Erick Perez Sifontes
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Eduard Shaykhinurov
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Kevin Jaatinen
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Tisha Jepson
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, USA
- True Bearing Diagnostics, Washington, DC, USA
| | - John E Lafleur
- Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - David Yamane
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - John Perkins
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Mary Pasquale
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Brian Giang
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Matthew McHarg
- Department of Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Zach Falk
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, USA
| | - Timothy A McCaffrey
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, USA
- True Bearing Diagnostics, Washington, DC, USA
- Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University Medical Center, Washington, DC, USA
| |
Collapse
|
2
|
Feltes J, Popova M, Hussein Y, Pierce A, Yamane D. Thrombolytics in Cardiac Arrest from Pulmonary Embolism: A Systematic Review and Meta Analysis. J Intensive Care Med 2024; 39:477-483. [PMID: 38037310 DOI: 10.1177/08850666231214754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND During cardiopulmonary resuscitation, intravenous thrombolytics are commonly used for patients whose underlying etiology of cardiac arrest is presumed to be related to pulmonary embolism (PE). METHODS We performed a systematic review and meta-analysis of the existing literature that focused on the use of thrombolytics for cardiac arrest due to presumed or confirmed PE. Outcomes of interest were return of spontaneous circulation (ROSC), survival to hospital discharge, neurologically-intact survival, and bleeding complications. RESULTS Thirteen studies with a total of 803 patients were included in this review. Most studies included were single-armed and retrospective. Thrombolytic agent and dose were heterogeneous between studies. Among those with control groups, intravenous thrombolysis was associated with higher rates of ROSC (OR 2.55, 95% CI = 1.50-4.34), but without a significant difference in survival to hospital discharge (OR 1.41, 95% CI = 0.79-2.41) or bleeding complications (OR 2.21, 0.95-5.17). CONCLUSIONS Use of intravenous thrombolytics in cardiac arrest due to confirmed or presumed PE is associated with increased ROSC but not survival to hospital discharge or change in bleeding complications. Larger randomized studies are needed. Currently, we recommend continuing to follow existing consensus guidelines which support use of thrombolytics for this indication.
Collapse
Affiliation(s)
- Jordan Feltes
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Margarita Popova
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Yasir Hussein
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ayal Pierce
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| |
Collapse
|
3
|
Fassas S, King D, Shay M, Schockett E, Yamane D, Hawkins K. Palliative Medicine and End of Life Care Between Races in an Academic Intensive Care Unit. J Intensive Care Med 2024; 39:250-256. [PMID: 37674378 DOI: 10.1177/08850666231200383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Background: Although palliative medicine (PM) is more commonly being integrated into the intensive care unit (ICU), research on racial disparities in this area is lacking. Our objectives were to (a) identify racial disparities in utilization of PM consultation for patients who received ICU care and (b) determine if there were differences in the use of code status or PM consultation over time based on race. Materials and Methods: Retrospective analysis of 571 patients, 18 years and above, at a tertiary care institution who received ICU care and died during their hospital stay. We analyzed two timeframes, 2008-2009 and 2018-2019. Univariate analysis was utilized to evaluate baseline characteristics. A multivariate logistic regression model and interaction P values were employed to assess for differential use of PM consultation, do not resuscitate (DNR) orders, and comfort care (CC) orders between races in aggregate and for changes over time. Results: There was a notable increase in Black/African-American (AA) (54% to 61%) and Hispanic/Latino (2% to 3%) patients over time in our population. Compared to White patients, we found no differences between PM consultation and CC orders. There was a lower probability of DNR orders for Black/AA (adjusted odds ratio [aOR] 0.569; P = .049; confidence interval [CI]: 0.324-0.997) and other/unknown/multiracial patients (aOR: 0.389; P = .273; CI: 0.169-0.900). Comparing our earlier time period to the later time period, we found an increased usage of PM for all patients. Interaction P values suggest there were no differences between races regarding PM, DNR, and CC orders. Conclusions: PM use has increased over time at our institution. Contrary to the previous literature, there were no differences in the frequency of utilization of PM consultation between races. Further analysis to evaluate the usage of PM in the ICU setting in varying populations and geographic locations is warranted.
Collapse
Affiliation(s)
- Scott Fassas
- George Washington University Hospital, Washington, DC, USA
| | - Daniel King
- George Washington University Hospital, Washington, DC, USA
| | - Molly Shay
- George Washington University Hospital, Washington, DC, USA
| | | | - David Yamane
- George Washington University Hospital, Washington, DC, USA
| | | |
Collapse
|
4
|
Prasanna N, DelPrete B, Ho G, Yamane D, Elshikh A, Rashed A, Sparks A, Davison D, Hawkins K. The utility of bandemia in prognostication and prediction of mortality in sepsis. J Intensive Care Soc 2023; 24:201-205. [PMID: 37260424 PMCID: PMC10227906 DOI: 10.1177/17511437211069307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Background: Bandemia, defined as a band count >10%, is indicative of underlying infection and is increasingly being used for early detection of sepsis. While an absolute band level has been linked to worse outcomes, its trend has not been extensively studied as a prognostic marker. In this study, we assessed patients admitted to the ICU with sepsis or septic shock and evaluated the correlation between bandemia trends and clinical trajectory among these patients. Methods: This study was a retrospective chart review. Band counts, serum lactate levels, and SOFA scores at 0 and 72 h after admission to the ICU were collected. Patients were risk stratified into groups depending on their SOFA trends, and corresponding band trends and serum lactate levels were compared. Results: 134 patients were included for analysis. There was a statistically significant decrease in bandemia trends for patients with a reduction in SOFA scores [median (IQR)-4.5 (-11, 0); p < 0.0001], and a statistically significant increase in bandemia trends for patients with worsening SOFA scores [median (IQR) 4 (0, 8); p = 0.0007]. Conclusion: Early trends of serum band levels in patients with sepsis or septic shock may help to predict a clinical trajectory and overall prognosis. More investigation is warranted as to whether incorporating bandemia trends, when used in conjunction with other known markers such as lactate levels, may help to guide bedside clinical decisions such as risk stratification, tailored therapies, and ultimately improve outcomes.
Collapse
Affiliation(s)
- Nivedita Prasanna
- Department of Critical Care
Medicine, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| | - Benjamin DelPrete
- Department of Critical Care
Medicine, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| | - Geoffrey Ho
- Department of Critical Care
Medicine, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| | - David Yamane
- Department of Critical Care
Medicine, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| | - Amira Elshikh
- Department of Critical Care
Medicine, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| | - Amir Rashed
- Department of Critical Care
Medicine, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| | - Andrew Sparks
- Department of Surgery, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| | - Danielle Davison
- Department of Critical Care
Medicine, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| | - Katrina Hawkins
- Department of Critical Care
Medicine, George Washington University School
of Medicine and Health Sciences, Washington, DC, USA
| |
Collapse
|
5
|
Rizvi G, Marcinkowski B, Srinivasa N, Jett A, Benjenk I, Davison D, Yamane D. Impact on Blood Product Utilization with Thromboelastography Guided Resuscitation for Gastrointestinal Hemorrhage. J Intensive Care Med 2023; 38:368-374. [PMID: 36112899 DOI: 10.1177/08850666221126661] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Thromboelastography (TEG) can guide transfusion therapy in trauma and has been associated with decreased transfusion requirements. This population differs from the medical population where the most common bleeding source is gastrointestinal hemorrhage (GIB). The utility of TEG in patients with acute GIB is not well described. We sought to assess whether the use of TEG impacts blood product utilization in patients with medical GIB. METHODS A retrospective study looking at all adult patients admitted with a primary diagnosis of GIB to the George Washington University Intensive Care Unit (ICU) between 01/01/2017 to 12/31/2019. The primary intervention was the use of TEG to guide blood product resuscitation in addition to standard of care (TEG arm) versus standard of care alone (non-TEG arm). RESULTS The primary outcome was the total number of blood products utilized. Patients in the TEG arm used more blood products compared to the non-TEG arm (9.10 vs 3.60, p < 0.001). There was no difference in secondary endpoints except for an increased requirement for mechanical ventilation within the TEG arm (26.2% vs 13.4%, p = 0.018). CONCLUSIONS The use of TEG to guide resuscitation in patients with acute GIB may be associated with increased blood product utilization without any clinical benefit to patient-centered outcomes.
Collapse
Affiliation(s)
- Ghazi Rizvi
- Department of Anesthesiology and Critical Care, 43963George Washington University Hospital, Washington, DC, USA.,Department of Internal Medicine, Division of Pulmonary & Critical Care Medicine, University of Texas Health Science Center, Houston, TX, USA
| | - Bridget Marcinkowski
- 43989School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Nandan Srinivasa
- 43989School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Alex Jett
- 43989School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
| | - Ivy Benjenk
- Department of Anesthesiology and Critical Care, 43963George Washington University Hospital, Washington, DC, USA
| | - Danielle Davison
- Department of Anesthesiology and Critical Care, 43963George Washington University Hospital, Washington, DC, USA
| | - David Yamane
- Department of Anesthesiology and Critical Care, 43963George Washington University Hospital, Washington, DC, USA
| |
Collapse
|
6
|
Pierce A, Brooks J, Popova M, Feltes J, Organick-Lee J, Hussein Y, Boone K, Winsten S, Yamane D. 1041: LOST IN TRANSLATION: VIDEO REVIEW TO ASSESS EMS HANDOFF IN OUT-OF-HOSPITAL CARDIAC ARREST. Crit Care Med 2023. [DOI: 10.1097/01.ccm.0000909892.56929.2d] [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: 12/23/2022]
|
7
|
Winsten S, Organick-Lee J, Feltes J, Brophy J, Pierce A, Hussein Y, Boone K, Popova M, Brooks J, Yamane D. 1156: THE BYSTANDER EFFECT: THE INFLUENCE OF KNOWN BYSTANDER CPR AND WITNESSED ARREST ON ED CPR DURATION. Crit Care Med 2023. [DOI: 10.1097/01.ccm.0000910360.28556.3a] [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: 12/23/2022]
|
8
|
Kartiko S, Koizumi N, Yamane D, Sarani B, Siddique AB, Levine AR, Jackson AM, Wieruszewski PM, Smischney NJ, Khanna AK, Chow JH. Thromboelastography Parameters do not Discriminate for Thrombotic Events in Hospitalized Patients With COVID-19. J Intensive Care Med 2022; 38:449-456. [PMID: 36448250 PMCID: PMC9713537 DOI: 10.1177/08850666221142265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) is associated with a prothrombotic state; leading to multiple sequelae. We sought to detect whether thromboelastography (TEG) parameters would be able to detect thromboembolic events in patients hospitalized with COVID-19. Methods We performed a retrospective multicenter case–control study of the Collaborative Research to Understand the Sequelae of Harm in COVID (CRUSH COVID) registry of 8 tertiary care level hospitals in the United States (US). This registry contains adult patients with COVID-19 hospitalized between March 2020 and September 2020. Results A total of 277 hospitalized COVID-19 patients were analyzed to determine whether conventional coagulation TEG parameters were associated with venous thromboembolic (VTE) and thrombotic events during hospitalization. A clotting index (CI) >3 was present in 45.8% of the population, consistent with a hypercoagulable state. Eighty-three percent of the patients had clot lysis at 30 min (LY30) = 0, consistent with fibrinolysis shutdown, with a median of 0.1%. We did not find TEG parameters (LY30 area under the receiver operating characteristic [ROC] curve [AUC] = 0.55, 95% CI: 0.44-0.65, P value = .32; alpha angle [α] AUC = 0.58, 95% CI: 0.47-0.69, P value = .17; K time AUC = 0.58, 95% CI: 0.46-0.69, P value = .67; maximum amplitude (MA) AUC = 0.54, 95% CI: 0.44-0.64, P value = .47; reaction time [R time] AUC = 0.53, 95% CI: 0.42-0.65, P value = .70) to be a good discriminator for VTE. We also did not find TEG parameters (LY30 AUC = 0.51, 95% CI: 0.42-0.60, P value = .84; R time AUC = 0.57, 95%CI: 0.48-0.67, P value .07; α AUC = 0.59, 95%CI: 0.51-0.68, P value = .02; K time AUC = 0.62, 95% CI: 0.53-0.70, P value = .07; MA AUC = 0.65, 95% CI: 0.57-0.74, P value < .01) to be a good discriminator for thrombotic events. Conclusions In this retrospective multicenter cohort study, TEG in COVID-19 hospitalized patients may indicate a hypercoagulable state, however, its use in detecting VTE or thrombotic events is limited in this population.
Collapse
Affiliation(s)
- Susan Kartiko
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Naoru Koizumi
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- George Mason University, Schar School of Policy and Government, Fairfax, VA, USA
| | - David Yamane
- Department of Emergency Medicine, Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Babak Sarani
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Abu B. Siddique
- George Mason University, Schar School of Policy and Government, Fairfax, VA, USA
| | - Andrea R. Levine
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amanda M. Jackson
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Madigan Army Medical Center, Joint Base Lewis–McChord, WA, USA
| | - Patrick M. Wieruszewski
- Departments of Anesthesiology and Pharmacy, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nathan J. Smischney
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ashish K. Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Jonathan H. Chow
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | |
Collapse
|
9
|
Wargodsky R, Dela Cruz P, LaFleur J, Yamane D, Kim JS, Benjenk I, Heinz E, Irondi OO, Farrar K, Toma I, Jordan T, Goldman J, McCaffrey TA. RNA Sequencing in COVID-19 patients identifies neutrophil activation biomarkers as a promising diagnostic platform for infections. PLoS One 2022; 17:e0261679. [PMID: 35081105 PMCID: PMC8791486 DOI: 10.1371/journal.pone.0261679] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/09/2021] [Indexed: 11/19/2022] Open
Abstract
Infection with the SARS-CoV2 virus can vary from asymptomatic, or flu-like with moderate disease, up to critically severe. Severe disease, termed COVID-19, involves acute respiratory deterioration that is frequently fatal. To understand the highly variable presentation, and identify biomarkers for disease severity, blood RNA from COVID-19 patient in an intensive care unit was analyzed by whole transcriptome RNA sequencing. Both SARS-CoV2 infection and the severity of COVID-19 syndrome were associated with up to 25-fold increased expression of neutrophil-related transcripts, such as neutrophil defensin 1 (DEFA1), and 3-5-fold reductions in T cell related transcripts such as the T cell receptor (TCR). The DEFA1 RNA level detected SARS-CoV2 viremia with 95.5% sensitivity, when viremia was measured by ddPCR of whole blood RNA. Purified CD15+ neutrophils from COVID-19 patients were increased in abundance and showed striking increases in nuclear DNA staining by DAPI. Concurrently, they showed >10-fold higher elastase activity than normal controls, and correcting for their increased abundance, still showed 5-fold higher elastase activity per cell. Despite higher CD15+ neutrophil elastase activity, elastase activity was extremely low in plasma from the same patients. Collectively, the data supports the model that increased neutrophil and decreased T cell activity is associated with increased COVID-19 severity, and suggests that blood DEFA1 RNA levels and neutrophil elastase activity, both involved in neutrophil extracellular traps (NETs), may be informative biomarkers of host immune activity after viral infection.
Collapse
Affiliation(s)
- Richard Wargodsky
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Philip Dela Cruz
- Department Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - John LaFleur
- Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - David Yamane
- Department Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, United States of America
- Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Justin Sungmin Kim
- Department Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Ivy Benjenk
- Department Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Eric Heinz
- Department Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Obinna Ome Irondi
- Department Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Katherine Farrar
- Department Anesthesiology and Critical Care Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Ian Toma
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, United States of America
- Department of Clinical Research and Leadership The George Washington University Medical Center, Washington, DC, United States of America
- True Bearing Diagnostics, Washington, DC, United States of America
| | - Tristan Jordan
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Jennifer Goldman
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| | - Timothy A. McCaffrey
- Department of Medicine, Division of Genomic Medicine, The George Washington University Medical Center, Washington, DC, United States of America
- Department of Clinical Research and Leadership The George Washington University Medical Center, Washington, DC, United States of America
- True Bearing Diagnostics, Washington, DC, United States of America
- Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University Medical Center, Washington, DC, United States of America
| |
Collapse
|
10
|
King D, Schockett E, Rizvi G, Fischer D, Amdur R, Benjenk I, Yamane D, DelPrete B, Davison D, Seneff M. The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit. J Intensive Care Med 2022; 37:1397-1402. [PMID: 35006025 DOI: 10.1177/08850666211069031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Dying in the intensive care unit (ICU) has changed over the last twenty years due to increased utilization of palliative care. We sought to examine how palliative medicine (PM) integration into critical care medicine has changed outcomes in end of life including the utilization of do not resuscitate (no cardiopulmonary resuscitation but continue treatment) and comfort care orders (No resuscitation, only comfort medication). Design: Retrospective observational review of critical care patients who died during admission between two decades, 2008 to 09 and 2018 to 19. Setting: Single urban tertiary care academic medical center in Washington, D.C. Patients: Adult patients who were treated in any ICU during the admission which they died. INTERVENTIONS AND MEASUREMENTS We sought to measure PM involvement across the two decades and its association with end of life care including do not resuscitate (DNR) and comfort care (CC) orders. Main Results: 571 cases were analyzed. Mean age was 65 ± 15, 46% were female. In univariate analysis significantly more patients received PM in 2018 to 19 (40% vs. 27%, p = .002). DNR status increased significantly over time (74% to 84%, p = .002) and was significantly more common in patients who were receiving PM (96% vs. 72%, p < 0.001). CC also increased over time (56% to 70%, p = <0.001), and was more common in PM patients (87% vs. 53%, p < 0.001). Death in the ICU decreased significantly over time (94% to 86%, p = .002) and was significantly lower in PM patients (76% vs. 96%, p < 0.001). The adjusted odds of getting CC for those receiving versus those not receiving PM were 14.51 (5.49-38.36, p < 0.001) in 2008 to 09 versus 3.89 (2.27-6.68, p < 0.001) in 2018 to 19. Conclusion: PM involvement increased significantly across a decade in our ICU and was significantly associated with incidence of DNR and CC orders as well as the decreased incidence of dying in the ICU. The increase in DNR and CC orders independent of PM over the past decade reflect intensivists delivering PM services.
Collapse
Affiliation(s)
- Daniel King
- 43963George Washington University Hospital, Washington, DC, USA
| | - Erica Schockett
- 43963George Washington University Hospital, Washington, DC, USA
| | - Ghazi Rizvi
- 43963George Washington University Hospital, Washington, DC, USA
| | - Daniel Fischer
- 43963George Washington University Hospital, Washington, DC, USA
| | - Richard Amdur
- 43963George Washington University Hospital, Washington, DC, USA
| | - Ivy Benjenk
- 43963George Washington University Hospital, Washington, DC, USA
| | - David Yamane
- 43963George Washington University Hospital, Washington, DC, USA
| | | | | | - Michael Seneff
- 43963George Washington University Hospital, Washington, DC, USA
| |
Collapse
|
11
|
Brooks JT, Pierce AZ, McCarville P, Sullivan N, Rahimi-Saber A, Payette C, Popova M, Koizumi N, Pourmand A, Yamane D. Video case review for quality improvement during cardiac arrest resuscitation in the emergency department. Int J Clin Pract 2021; 75:e14525. [PMID: 34120384 DOI: 10.1111/ijcp.14525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrests are a leading global cause of mortality. The American Heart Association (AHA) promotes several important strategies associated with improved cardiac arrest (CA) outcomes, including decreasing pulse check time and maintaining a chest compression fraction (CCF) > 0.80. Video review is a potential tool to improve skills and analyse deficiencies in various situations; however, its use in improving medical resuscitation remains poorly studied in the emergency department (ED). We implemented a quality improvement initiative, which utilised video review of CA resuscitations in an effort to improve compliance with such AHA quality metrics. METHODS A cardiopulmonary resuscitation video review team of emergency medicine residents were assembled to analyse CA resuscitations in our urban academic ED. Videos were reviewed by two residents, one of whom was a senior resident (Postgraduate Year 3 or 4), and analysed using Spearman's rank correlation coefficient for numerous quality improvement metrics, including pulse check time, CCF, time to intravenous access and time to patient attached to monitor. RESULTS We collected data on 94 CA resuscitations between July 2017 and June 2020. Average pulse check time was 13.09 (SD ± 5.97) seconds, and 38% of pulse checks were <10 seconds. After the implementation of the video review process, there was a significant decrease in average pulse check time (P = .01) and a significant increase in CCF (P = .01) throughout the study period. CONCLUSIONS Our study suggests that the video review and feedback process was significantly associated with improvements in AHA quality metrics for resuscitation in CA amongst patients presented to the ED.
Collapse
Affiliation(s)
- Joseph T Brooks
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ayal Z Pierce
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Patrick McCarville
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Natalie Sullivan
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Anahita Rahimi-Saber
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Christopher Payette
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Margarita Popova
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Narou Koizumi
- School of Policy and Government, George Mason University, Arlington, VA, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| |
Collapse
|
12
|
Rizvi G, Yamane D, Davison D, Williams J, Heinz ER. Sedation, narcotic and neuromuscular blockade in mechanically ventilated patients with COVID-19. Trends Anaesth Crit Care 2021; 39:19-20. [PMID: 38620832 PMCID: PMC8184364 DOI: 10.1016/j.tacc.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
Objective To describe the sedation, narcotic and neuromuscular blockade usage in ventilated patients with COVID-19 pneumonia. Design Single-Center Retrospective Review. Setting George Washington University Hospital in Washington, D.C. Patients 62 patients with COVID-19 respiratory failure requiring mechanical ventilation admitted from March 2020 to June 2020. Intervention None. Measurements and main results Patients with COVID-19 respiratory failure required multiple sedative/narcotic infusions to achieve sedation requirements and at doses that were significantly more when compared to a general medical-surgical ICU population (represented by the MIND-USA cohort). The most common infusions were Dexmedetomadine and Propofol. Approximately 17% of our patients required a neuromuscular blockade infusion as well. Prior to intubation, narcotic utilization was stable and low. Conclusion Patients with COVID-19 respiratory failure requiring mechanical ventilation have higher sedation and narcotic requirements than general ICU patients.
Collapse
Affiliation(s)
- Ghazi Rizvi
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Located at, 900 23rd Street, NW, Washington DC, 20037, USA
| | - David Yamane
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Located at, 900 23rd Street, NW, Washington DC, 20037, USA
| | - Danielle Davison
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Located at, 900 23rd Street, NW, Washington DC, 20037, USA
| | - Jeffrey Williams
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Located at, 900 23rd Street, NW, Washington DC, 20037, USA
| | - Eric R Heinz
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Located at, 900 23rd Street, NW, Washington DC, 20037, USA
| |
Collapse
|
13
|
Schockett E, Ishola M, Wahrenbrock T, Croskey A, Cain S, Benjenk I, Davison D, Yamane D. The Impact of Integrating Palliative Medicine Into COVID-19 Critical Care. J Pain Symptom Manage 2021; 62:153-158.e1. [PMID: 33359039 PMCID: PMC7871105 DOI: 10.1016/j.jpainsymman.2020.12.014] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ensuring high-quality patient-centered care for critically ill coronavirus disease 2019 (COVID-19) patients presents unprecedented challenges. Many patients become critically ill unexpectedly and have not previously discussed their health-care wishes. Clinicians lack experience with this illness and therefore struggle to predict patient outcomes. MEASURES Critical care medicine (CCM) providers were surveyed about the effectiveness and efficiency of a pilot intervention. INTERVENTION Proactive palliative care rounding with CCM providers on COVID-19 intensive care units. OUTCOMES Fifty-four percent of CCM providers responded to the survey (21/39). CCM providers rated the intervention highly across all domains. CCM providers frequently identified that early palliative involvement was critical to providing families with information and support when separated from their loved ones. CONCLUSIONS/LESSONS LEARNED This pilot study found that proactive rounding improves critical care provider assessments of quality of care for patients and families and allows CCM providers to focus their efforts on managing complex physiology and surges.
Collapse
Affiliation(s)
- Erica Schockett
- Assistant Professor, Department of Internal Medicine, The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA.
| | - Mary Ishola
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Taylor Wahrenbrock
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Annabelle Croskey
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Shannon Cain
- The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Ivy Benjenk
- Research Coordinator, Department of Anesthesia and Critical Care Medicine, The George Washington University, Washington, District of Columbia, USA
| | - Danielle Davison
- Associate Professor, Department of Anesthesia and Critical Care Medicine, Associate Professor, Department of Internal Medicine, The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - David Yamane
- Assistant Professor, Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, The George Washington University School of Medicine & Health Sciences, Washington, District of Columbia, USA
| |
Collapse
|
14
|
Chow JH, Khanna AK, Kethireddy S, Yamane D, Levine A, Jackson AM, McCurdy MT, Tabatabai A, Kumar G, Park P, Benjenk I, Menaker J, Ahmed N, Glidewell E, Presutto E, Cain S, Haridasa N, Field W, Fowler JG, Trinh D, Johnson KN, Kaur A, Lee A, Sebastian K, Ulrich A, Peña S, Carpenter R, Sudhakar S, Uppal P, Fedeles BT, Sachs A, Dahbour L, Teeter W, Tanaka K, Galvagno SM, Herr DL, Scalea TM, Mazzeffi MA. Aspirin Use Is Associated With Decreased Mechanical Ventilation, Intensive Care Unit Admission, and In-Hospital Mortality in Hospitalized Patients With Coronavirus Disease 2019. Anesth Analg 2021; 132:930-941. [PMID: 33093359 DOI: 10.1213/ane.0000000000005292] [Citation(s) in RCA: 205] [Impact Index Per Article: 68.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronavirus disease-2019 (COVID-19) is associated with hypercoagulability and increased thrombotic risk in critically ill patients. To our knowledge, no studies have evaluated whether aspirin use is associated with reduced risk of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality. METHODS A retrospective, observational cohort study of adult patients admitted with COVID-19 to multiple hospitals in the United States between March 2020 and July 2020 was performed. The primary outcome was the need for mechanical ventilation. Secondary outcomes were ICU admission and in-hospital mortality. Adjusted hazard ratios (HRs) for study outcomes were calculated using Cox-proportional hazards models after adjustment for the effects of demographics and comorbid conditions. RESULTS Four hundred twelve patients were included in the study. Three hundred fourteen patients (76.3%) did not receive aspirin, while 98 patients (23.7%) received aspirin within 24 hours of admission or 7 days before admission. Aspirin use had a crude association with less mechanical ventilation (35.7% aspirin versus 48.4% nonaspirin, P = .03) and ICU admission (38.8% aspirin versus 51.0% nonaspirin, P = .04), but no crude association with in-hospital mortality (26.5% aspirin versus 23.2% nonaspirin, P = .51). After adjusting for 8 confounding variables, aspirin use was independently associated with decreased risk of mechanical ventilation (adjusted HR, 0.56, 95% confidence interval [CI], 0.37-0.85, P = .007), ICU admission (adjusted HR, 0.57, 95% CI, 0.38-0.85, P = .005), and in-hospital mortality (adjusted HR, 0.53, 95% CI, 0.31-0.90, P = .02). There were no differences in major bleeding (P = .69) or overt thrombosis (P = .82) between aspirin users and nonaspirin users. CONCLUSIONS Aspirin use may be associated with improved outcomes in hospitalized COVID-19 patients. However, a sufficiently powered randomized controlled trial is needed to assess whether a causal relationship exists between aspirin use and reduced lung injury and mortality in COVID-19 patients.
Collapse
Affiliation(s)
- Jonathan H Chow
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine, Washington, DC
| | - Ashish K Khanna
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Shravan Kethireddy
- Division of Pulmonary and Critical Care, Department of Medicine, Northeast Georgia Health System, Gainesville, Georgia
| | - David Yamane
- Departments of Emergency Medicine, Anesthesiology, and Critical Care Medicine, George Washington University School of Medicine, Washington, DC
| | - Andrea Levine
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda M Jackson
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ali Tabatabai
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Gagan Kumar
- Division of Pulmonary and Critical Care, Department of Medicine, Northeast Georgia Health System, Gainesville, Georgia
| | - Paul Park
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ivy Benjenk
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine, Washington, DC
| | - Jay Menaker
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine, Washington, DC.,Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio.,Division of Pulmonary and Critical Care, Department of Medicine, Northeast Georgia Health System, Gainesville, Georgia.,Departments of Emergency Medicine, Anesthesiology, and Critical Care Medicine, George Washington University School of Medicine, Washington, DC.,Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.,Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland.,Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland.,Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Medicine, Northeast Georgia Health System, Gainesville, Georgia.,Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland.,Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Surgery, University of California San Francisco, San Francisco, California.,Department of Anesthesiology, The University of Oklahoma School of Medicine, Oklahoma City, Oklahoma
| | - Nayab Ahmed
- Department of Medicine, Northeast Georgia Health System, Gainesville, Georgia
| | - Evan Glidewell
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Elizabeth Presutto
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shannon Cain
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC
| | - Naeha Haridasa
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine, Washington, DC
| | - Wesley Field
- Department of Medicine, Northeast Georgia Health System, Gainesville, Georgia
| | - Jacob G Fowler
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Duy Trinh
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kathleen N Johnson
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Aman Kaur
- Department of Medicine, Northeast Georgia Health System, Gainesville, Georgia
| | - Amanda Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kyle Sebastian
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Allison Ulrich
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Salvador Peña
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ross Carpenter
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shruti Sudhakar
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Pushpinder Uppal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Benjamin T Fedeles
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aaron Sachs
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Layth Dahbour
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - William Teeter
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi Tanaka
- Department of Anesthesiology, The University of Oklahoma School of Medicine, Oklahoma City, Oklahoma
| | - Samuel M Galvagno
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Daniel L Herr
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland.,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
15
|
King D, Davison D, Benjenk I, Heinz E, Vaziri K, Hawkins K, Yamane D. YouTube to Teach Central Lines, The Expert vs Learner Perspective. J Intensive Care Med 2021; 37:528-534. [PMID: 33715501 DOI: 10.1177/0885066621999979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Instructional videos of medical procedures can be a useful guide for learners, demonstrating proper and safe technique. Open publishing sites such as YouTube are readily accessible, however the content is not peer reviewed and quality of videos vary greatly. Our aim was to evaluate a learner's ability to interpret the quality of openly published content by comparing their rating of the most popular central line insertion videos on YouTube to expert evaluations. METHOD YouTube search results for "central line placement" sorted by views or relevance compiled a list of the four most common videos. A fifth gold standard video, published by the New England Journal, was included, however was not found in the top results. Eleven expert practitioners from varying medical specialties (Critical Care, Surgery, Anesthesia, & Emergency Medicine) evaluated the 5 videos, utilizing a 22-item Likert scaled questionnaire emphasizing: preparation, sterility, anatomy, technique, & complications. Videos were compared as a composite average of the individual items on the survey. The highest, lowest, and 3rd ranked videos were evaluated by 45 residents ("learners") in varying specialties (Internal Medicine, Emergency Medicine, Surgery, Anesthesia) and post graduate year (PGY). Learners assessed the videos using the same scale. A Welch T-test assessed statistical significance between the two groups. Subgroup analysis compared experts against different PGY and specialty cohorts. RESULTS The lowest scored video among the experts and learners was the most popular on YouTube, with 858,933 views at the time of inclusion. Though lowest in rank, this video was judged higher by learners than the experts (2.63/5 vs 2.18/5, P = 0.0029). The 3rd ranked video by experts with 249,746 views on YouTube, was also rated higher by learners (3.77/5 vs 3.45/5, P = 0.0084). The gold standard video by NEJM had 320,580 views and was rated highest by both the experts and learners (4.37/5 vs 4.28/5, P = 0.518). Subgroup analysis showed similar results with learners rating the videos overall better than experts, this was particularly true in the PGY-1 subgroup. CONCLUSION The most popular central line insertion video was the worst rated by both experts and learners. Learners rated all the videos better than the expert. YouTube videos demonstrating medical procedures including central line insertion should come from peer reviewed sources if they are to be incorporated into educational curriculum.
Collapse
Affiliation(s)
- Daniel King
- University of Maryland, Prince Georges Hospital Center, Cheverly, MD, USA.,Department of Anesthesia and Critical Care, George Washington University, Washington, DC, USA
| | - Danielle Davison
- Department of Anesthesia and Critical Care, George Washington University, Washington, DC, USA
| | - Ivy Benjenk
- Department of Anesthesia and Critical Care, George Washington University, Washington, DC, USA
| | - Eric Heinz
- Department of Anesthesia and Critical Care, George Washington University, Washington, DC, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Katrina Hawkins
- Department of Anesthesia and Critical Care, George Washington University, Washington, DC, USA
| | - David Yamane
- Department of Anesthesia and Critical Care, George Washington University, Washington, DC, USA.,Department of Emergency Medicine, George Washington University, Washington, DC, USA
| |
Collapse
|
16
|
Ramamurti P, Yamane D, Desai S, Boniface K, Drake A. Mortality in patients with hepatic gas on point-of-care ultrasound in cardiac arrest: Does location matter? J Clin Ultrasound 2021; 49:205-211. [PMID: 33225452 DOI: 10.1002/jcu.22952] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/20/2020] [Accepted: 11/03/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Prior research has suggested an association of hepatic venous gas with mortality in cardiac arrest. As point of care ultrasound (POCUS) is frequently used in the context of resuscitation, we sought to evaluate if the presence of hepatic gas on POCUS had a similar mortality association. METHODS A retrospective review was conducted of patients who experienced nontraumatic cardiac arrest. Archived ultrasound images were independently reviewed to determine the presence of gas in the hepatic parenchyma and vasculature. Electronic medical records were then reviewed to collect remaining clinical data. RESULTS From 1 January 2017 through 16 June 2019, 87 patients met inclusion criteria. Among them, 68 (78.2%) patients died. Among those who died, 40 (58.8%) had hepatic gas, while 28 (41.2%) had none. Only a single survivor demonstrated hepatic venous gas (11%). While the difference in mortality with respect to presence of undifferentiated hepatic gas was not significant (P = .37), there was a significant difference with respect to the presence of venous gas (P = .004). CONCLUSION Our study demonstrated that the incidence of postarrest hepatic gas on POCUS was common, and that the presence of hepatic venous gas during cardiac resuscitation was associated with increased mortality, while hepatic parenchymal gas alone was not.
Collapse
Affiliation(s)
- Pradip Ramamurti
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - David Yamane
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Department of Anesthesia and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Sajani Desai
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Keith Boniface
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Aaran Drake
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| |
Collapse
|
17
|
Rodriguez S, Archuleta C, Ben-Maimon S, Yamane D, Benjenk I, Pla R, Brooks J. 155: Can It Wait? Do Delays in Presentation Affect Outcomes in COVID-19 Patients? Crit Care Med 2021. [DOI: 10.1097/01.ccm.0000726508.40520.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
18
|
Prasanna N, Hung CM, Cruz PD, Okezue C, Chu E, Farrar K, zhang S, Yamane D, Davison D, Seneff M. 278: Potential Biomarkers for Severe ARDS in the Setting of SARS-CoV-2 ICU Admission. Crit Care Med 2021. [DOI: 10.1097/01.ccm.0000727000.82080.e6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
19
|
Rogers HK, Choi WW, Gowda N, Nawal S, Gordon B, Onyilofor C, Rogers CM, Yamane D, Borum ML. Frequency and outcomes of gastrointestinal symptoms in patients with Corona Virus Disease-19. Indian J Gastroenterol 2021; 40:502-511. [PMID: 34569014 PMCID: PMC8475883 DOI: 10.1007/s12664-021-01191-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/03/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To characterize the frequency and association of gastrointestinal (GI) symptoms with outcomes in patients with corona virus disease 2019 (COVID-19) admitted to the hospital. METHODS Records were retrospectively collected from patients admitted to a tertiary care center in Washington, D.C., with confirmed COVID-19 from March 15, 2020 to July 15, 2020. After adjusting for clinical demographics and comorbidities, multivariate logistic regression analysis was performed. RESULTS The most common presenting symptoms of COVID-19 in patients that were admitted to the hospital were cough (38.4%), shortness of breath (37.5%), and fever (34.3%), followed by GI symptoms in 25.9% of patients. The most common GI symptom was diarrhea (12.8%) followed by nausea or vomiting (10.5%), decreased appetite (9.3%), and abdominal pain (3.8%). Patients with diarrhea were more likely to die (odds ratio [OR] 2.750; p = 0.006; confidence interval [CI] 1.329-5.688), be admitted to the intensive care unit (ICU) (OR 2.242; p = 0.019; CI 1.139-4.413), and be intubated (OR 3.155; p = 0.002; CI 1.535-6.487). Additional outcomes analyzed were need for vasopressors, presence of shock, and acute kidney injury. Patients with diarrhea were 2.738 (p = 0.007; CI 1.325-5.658), 2.467 (p = 0.013; CI 1.209-5.035), and 2.694 (p = 0.007; CI 1.305-5.561) times more likely to experience these outcomes, respectively. CONCLUSIONS Screening questions should be expanded to include common GI symptoms in patients with COVID-19. Health care providers should note whether their patient is presenting with diarrhea due to the potential implications on disease severity and outcomes.
Collapse
Affiliation(s)
- Hayley K. Rogers
- Department of Internal Medicine, George Washington University, 2150 Pennsylvania Avenue, NW Suite 5-416, Washington, D.C. 20037 USA
| | - WonSeok W. Choi
- Department of Internal Medicine, George Washington University, 2150 Pennsylvania Avenue, NW Suite 5-416, Washington, D.C. 20037 USA
| | - Niraj Gowda
- Department of Internal Medicine, George Washington University, 2150 Pennsylvania Avenue, NW Suite 5-416, Washington, D.C. 20037 USA
| | - Saadia Nawal
- Department of Internal Medicine, George Washington University, 2150 Pennsylvania Avenue, NW Suite 5-416, Washington, D.C. 20037 USA
| | - Brittney Gordon
- School of Medicine and Health Sciences, George Washington University, Ross Hall, 2300 Eye Street, NW, Washington, D.C. 20037 USA
| | - Chinelo Onyilofor
- School of Medicine and Health Sciences, George Washington University, Ross Hall, 2300 Eye Street, NW, Washington, D.C. 20037 USA
| | - Callie M. Rogers
- College of Veterinary Medicine and Biomedical Sciences, Texas A and M University, Veterinary and Biomedical Education Complex, 660 Raymond Stotzer Pkwy, College Station, 77843 TX USA
| | - David Yamane
- Department of Emergency Medicine, Department of Anesthesia and Critical Care, George Washington University, 900 23rd St NW, Washington, D.C. 20037 USA
| | - Marie L. Borum
- Division of Gastroenterology and Liver Diseases, George Washington University, 22nd and I Street, NW, 3rd Floor, Washington, D.C. 20037 USA
| |
Collapse
|
20
|
Yamane D, McCarville P, Sullivan N, Kuhl E, Lanam CR, Payette C, Rahimi-Saber A, Rabjohns J, Sparks AD, Boniface K, Drake A. Minimizing Pulse Check Duration Through Educational Video Review. West J Emerg Med 2020; 21:276-283. [PMID: 33207177 PMCID: PMC7673890 DOI: 10.5811/westjem.2020.8.47876] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/09/2020] [Indexed: 12/26/2022] Open
Abstract
Introduction The American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend pulse checks of less than 10 seconds. We assessed the effect of video review-based educational feedback on pulse check duration with and without point-of-care ultrasound (POCUS). Methods Cameras recorded cases of CPR in the emergency department (ED). Investigators reviewed resuscitation videos for ultrasound use during pulse check, pulse check duration, and compression-fraction ratio. Investigators reviewed health records for patient outcomes. Providers received written feedback regarding pulse check duration and compression-fraction ratio. Researchers reviewed selected videos in multidisciplinary grand round presentations, with research team members facilitating discussion. These presentations highlighted strategies that include the following: limit on pulse check duration; emphasis on compressions; and use of “record, then review” method for pulse checks with POCUS. The primary endpoint was pulse check duration with and without POCUS. Results Over 19 months, investigators reviewed 70 resuscitations with a total of 325 pulse checks. The mean pulse check duration was 11.5 ± 8.8 seconds (n = 224) and 13.8 ± 8.6 seconds (n = 101) without and with POCUS, respectively. POCUS pulse checks were significantly longer than those without POCUS (P = 0.001). Mean pulse check duration per three-month block decreased statistically significantly from study onset to the final study period (from 17.2 to 10 seconds [P<0.0001]) overall; decreased from 16.6 to 10.5 seconds (P<0.0001) without POCUS; and with POCUS from 19.8 to 9.88 seconds (P<0.0001) with POCUS. Pulse check times decreased significantly over the study period of educational interventions. The strongest effect size was found in POCUS pulse check duration (P = −0.3640, P = 0.002). Conclusion Consistent with previous studies, POCUS prolonged pulse checks. Educational interventions were associated with significantly decreased overall pulse-check duration, with an enhanced effect on pulse checks involving POCUS. Performance feedback and video review-based education can improve CPR by increasing chest compression-fraction ratio.
Collapse
Affiliation(s)
- David Yamane
- George Washington University, Department of Emergency Medicine, Washington DC.,George Washington University, Department of Anesthesiology and Critical Care Medicine, Washington DC
| | - Patrick McCarville
- George Washington University, Department of Emergency Medicine, Washington DC
| | - Natalie Sullivan
- George Washington University, Department of Emergency Medicine, Washington DC
| | - Evan Kuhl
- George Washington University, Department of Emergency Medicine, Washington DC
| | - Carolyn Robin Lanam
- George Washington University, Department of Emergency Medicine, Washington DC
| | - Christopher Payette
- George Washington University, Department of Emergency Medicine, Washington DC
| | | | - Jennifer Rabjohns
- George Washington University, Department of Emergency Medicine, Washington DC
| | - Andrew D Sparks
- George Washington University, Department of Emergency Medicine, Washington DC
| | - Keith Boniface
- George Washington University, Department of Emergency Medicine, Washington DC
| | - Aaran Drake
- George Washington University, Department of Emergency Medicine, Washington DC
| |
Collapse
|
21
|
Prasanna N, Yamane D, Haridasa N, Davison D, Sparks A, Hawkins K. Safety and efficacy of vasopressor administration through midline catheters. J Crit Care 2020; 61:1-4. [PMID: 33049486 DOI: 10.1016/j.jcrc.2020.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/04/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
CONTEXT Vasopressors are commonly administered through Central Venous Catheters (CVCs) as it is considered unsafe to administer them via peripheral IVs, mainly due to the concern of local tissue injury. Unlike peripheral IVs, midline catheters provide a wider lumen with the catheter tip ending in a large peripheral vein. The use of vasopressors through midline catheters has not yet been evaluated. OBJECTIVE The primary objective of this study is to determine the safety and efficacy of long term administration of vasopressors through a midline catheter. DESIGN This is a retrospective study between 2016 and 2019 looking at the outcomes of midline catheters. SETTING 45 bed Tertiary level ICU in a 600-bed teaching hospital. PATIENTS A total of 248 patients received vasopressors via midline catheters. RESULTS The average midline dwell time was 14.7 ± 12.8 days and the average duration of continuous vasopressor infusion was 7.8 ± 9.3 days. Vasopressors used with their average dose (AD) were norepinephrine (n = 165, 16.8 CE ± 10.7 μg/min), epinephrine (n = 56, 9.1 CE ± 6.0 μg/min), vasopressin (n = 123, 0.05 CE ± 0.02 units/min), phenylephrine (n = 158, 91.4 CE ± 64.7 μg/min) and Angiotensin II (50 CE ± 27.6 ng/kg/min). Early Complication rate was 3.6% due to Bloodstream infection (n = 6), drug extravasation (n = 1), thrombophlebitis (n = 1) and arterial puncture (n = 1). Late Complication rate was 0.8% (n = 2) due to midline-associated DVTs. There were no complications related to ineffective drug delivery or limb endangerment. CONCLUSIONS Many medical centers are attempting to limit the use of central venous catheters (CVCs) to avoid central line-associated bloodstream infections (CLABSIs). This study demonstrates that midline catheters are a safe alternative to CVCs, for the safe and efficacious administration of vasopressors for prolonged periods of time.
Collapse
Affiliation(s)
- Nivedita Prasanna
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Washington D.C., USA.
| | - David Yamane
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Washington D.C., USA
| | - Naeha Haridasa
- Department of George Washington University School of Medicine and Health Sciences, Washington D.C., USA
| | - Danielle Davison
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Washington D.C., USA
| | - Andrew Sparks
- Department of George Washington University School of Medicine and Health Sciences, Washington D.C., USA
| | - Katrina Hawkins
- Department of Anesthesiology and Critical Care, George Washington University Hospital, Washington D.C., USA
| |
Collapse
|
22
|
Rahimi-Saber A, Pierce A, McCarville P, Koizumi N, Sarkissian A, Tronnier A, Yamane D. 262 Don’t Let the Monitor Fool You: Pulse Check Variation between Shockable and Non-Shockable Rhythms. Ann Emerg Med 2020. [DOI: 10.1016/j.annemergmed.2020.09.276] [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: 10/23/2022]
|
23
|
Tronnier A, Mulcahy CF, Pierce A, Benjenk I, Sherman M, Heinz ER, Honeychurch S, Ho G, Talton K, Yamane D. COVID-19 Intubation Safety: A Multidisciplinary, Rapid-Cycle Model of Improvement. Am J Med Qual 2020; 35:450-457. [PMID: 32806935 PMCID: PMC7672671 DOI: 10.1177/1062860620949141] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The COVID-19 pandemic has forced the health care industry to develop dynamic protocols to maximize provider safety as aerosolizing procedures, specifically intubation, increase the risk of contracting SARS-CoV-2. The authors sought to create a quality improvement framework to ensure safe practices for intubating providers, and describe a multidisciplinary model developed at an academic tertiary care facility centered on rapid-cycle improvements and real-time gap analysis to track adherence to COVID-19 intubation safety protocols. The model included an Intubation Safety Checklist, a standardized documentation template for intubations, obtaining real-time feedback, and weekly multidisciplinary team meetings to review data and implement improvements. This study captured 68 intubations in suspected COVID-19 patients and demonstrated high personal protective equipment compliance at the institution, but also identified areas for process improvement. Overall, the authors posit that an interdisciplinary workgroup and the integration of standardized processes can be used to enhance intubation safety among providers during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Amy Tronnier
- The George Washington University, Washington, DC The George Washington University Hospital, Washington, DC
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Kumar V, Yamane D, Aljohani B, Alsabban A, Pourmand A. Double sequential external defibrillation. Resuscitation 2020; 152:212-213. [DOI: 10.1016/j.resuscitation.2020.05.015] [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] [Received: 04/15/2020] [Revised: 04/27/2020] [Accepted: 05/03/2020] [Indexed: 11/15/2022]
|
25
|
Pourmand A, Whiteside T, Yamane D, Rashed A, Mazer-Amirshahi M. The controversial role of corticosteroids in septic shock. Am J Emerg Med 2019; 37:1353-1361. [PMID: 31056383 DOI: 10.1016/j.ajem.2019.04.045] [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] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/13/2019] [Accepted: 04/25/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Several clinical trials and literature reviews have been conducted to evaluate the impact of corticosteroids on the physiological markers and clinical outcomes of patients in septic shock. While the findings have been somewhat contradictory, there is evidence of moderate benefit from the administration of low-dose corticosteroids to patients in septic shock. In this review, we discuss recent studies evaluating the impact of corticosteroids on morbidity and mortality in septic shock and explore future directions to fully elucidate when and how the administration of corticosteroid therapies can be beneficial. METHODS A literature review was performed using the Mesh database of PubMed with the term "septic shock" and subheadings "therapeutic use", "drug therapy", "pharmacology", and "therapy" followed by the addition of "steroid". Filters were added to restrict the search to 18+ age, English and human studies, and articles published within the last 10 years. One hundred sixty-five articles were examined and twenty-five were deemed relevant to this review. RESULTS The twenty-five articles reviewed here provide conflicting evidence as to the usefulness of corticosteroid treatments during septic shock. Several showed improved physiological outcomes, including rates of organ failure, need for life supporting interventions, adverse effects, inflammatory markers, and perfusion during the course of septic shock, as well as decreased mortality for a statistically significant number of patients. CONCLUSIONS There remains a need for improved therapy for patients in septic shock. Corticosteroids have shown some potential in improving mortality rates and clinical markers. Additional studies are needed to determine the optimal role of corticosteroids in septic shock.
Collapse
Affiliation(s)
- Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Tess Whiteside
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Amir Rashed
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States; Georgetown University School of Medicine, Washington, DC, United States
| |
Collapse
|
26
|
Pourmand A, Pyle M, Yamane D, Sumon K, Frasure SE. The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients. World J Emerg Med 2019; 10:232-238. [PMID: 31534598 DOI: 10.5847/wjem.j.1920-8642.2019.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Volume resuscitation has only been demonstrated to be effective in approximately fifty percent of patients. The remaining patients do not respond to volume resuscitation and may even develop adverse outcomes (such as acute pulmonary edema necessitating endotracheal intubation). We believe that point-of-care ultrasound is an excellent modality by which to adequately predict which patients may benefit from volume resuscitation. DATA RESOURCES We performed a search using PubMed, Scopus, and MEDLINE. The following search terms were used: fluid responsiveness, ultrasound, non-invasive, hemodynamic, fluid challenge, and passive leg raise. Preference was given to clinical trials and review articles that were most relevant to the topic of assessing a patient's cardiovascular ability to respond to intravenous fluid administration using ultrasound. RESULTS Point-of-care ultrasound can be easily employed to measure the diameter and collapsibility of various large vessels including the inferior vena cava, common carotid artery, subclavian vein, internal jugular vein, and femoral vein. Such parameters are closely related to dynamic measures of fluid responsiveness and can be used by providers to help guide fluid resuscitation in critically ill patients. CONCLUSION Ultrasound in combination with passive leg raise is a non-invasive, cost- and time-effective modality that can be employed to assess volume status and response to fluid resuscitation. Traditionally sonographic studies have focused on the evaluation of large veins such as the inferior vena cava, and internal jugular vein. A number of recently published studies also demonstrate the usefulness of evaluating large arteries to predict volume status.
Collapse
Affiliation(s)
- Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Matthew Pyle
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kazi Sumon
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sarah E Frasure
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| |
Collapse
|
27
|
Pourmand A, Galvis J, Yamane D. The controversial role of dual sequential defibrillation in shockable cardiac arrest. Am J Emerg Med 2018; 36:1674-1679. [DOI: 10.1016/j.ajem.2018.05.078] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 12/21/2022] Open
|
28
|
Elmer J, Yamane D, Hou PC, Wilcox SR, Bajwa EK, Hess DR, Camargo CA, Greenberg SM, Rosand J, Pallin DJ, Goldstein JN, Takhar SS. Cost and Utility of Microbiological Cultures Early After Intensive Care Unit Admission for Intracerebral Hemorrhage. Neurocrit Care 2017; 26:58-63. [PMID: 27605253 DOI: 10.1007/s12028-016-0285-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fever is common among intensive care unit (ICU) patients. Clinicians may use microbiological cultures to differentiate infectious and aseptic fever. However, their utility depends on the prevalence of infection; and false-positive results might adversely affect patient care. We sought to quantify the cost and utility of microbiological cultures in a cohort of ICU patients with spontaneous intracerebral hemorrhage (ICH). METHODS We performed a secondary analysis of a cohort with spontaneous ICH requiring mechanical ventilation. We collected baseline data, measures of systemic inflammation, microbiological culture results for the first 48 h, and daily antibiotic usage. Two physicians adjudicated true-positive and false-positive culture results using standard criteria. We calculated the cost per true-positive result and used logistic regression to test the association between false-positive results with subsequent antibiotic exposure. RESULTS Overall, 697 subjects were included. A total of 233 subjects had 432 blood cultures obtained, with one true-positive (diagnostic yield 0.1 %, $22,200 per true-positive) and 11 false-positives. True-positive urine cultures (5 %) and sputum cultures (13 %) were more common but so were false-positives (6 and 17 %, respectively). In adjusted analysis, false-positive blood and sputum results were associated with increased antibiotic exposure. CONCLUSIONS The yield of blood cultures early after spontaneous ICH was very low. False-positive results significantly increased the odds of antibiotic exposure. Our results support limiting the use of blood cultures in the first two days after ICU admission for spontaneous ICH.
Collapse
Affiliation(s)
- Jonathan Elmer
- Departments of Emergency Medicine and Critical Care Medicine, University of Pittsburgh, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA, 15213, USA.
| | - David Yamane
- Department of Anesthesiology and Critical Care Medicine, George Washington University Hospital, Washington, DC, USA
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Surgical Intensive Care Unit, Brigham and Women's Hospital, Boston, MA, USA
| | - Susan R Wilcox
- Divisions of Emergency Medicine and Pulmonary, Critical Care and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ednan K Bajwa
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Dean R Hess
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA, USA
- Department of Respiratory Care, Massachusetts General Hospital, Boston, MA, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel J Pallin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sukhjit S Takhar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
29
|
|
30
|
|
31
|
Jiang X, Tutana T, Yamane D, Osipchuk Y, Verdonk E, Costantin J. A Device to Measure Ligand- or Voltage-Gated Channels Simultanously in 384 Wells. Biophys J 2011. [DOI: 10.1016/j.bpj.2010.12.3572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
32
|
Verdonk E, Tutana T, Jiang X, Yamane D, Osipchuk Y, Costantin J. Simultaneous Recordings of Ligand-Gated Ion Channels using a 384 Planar Patch Clamp Substrate. Biophys J 2010. [DOI: 10.1016/j.bpj.2009.12.3286] [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: 10/19/2022] Open
|
33
|
Yamane D, Nagai M, Ogawa Y, Tohya Y, Akashi H. Enhancement of apoptosis via an extrinsic factor, TNF-alpha, in cells infected with cytopathic bovine viral diarrhea virus. Microbes Infect 2005; 7:1482-91. [PMID: 16055364 DOI: 10.1016/j.micinf.2005.05.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2005] [Revised: 05/02/2005] [Accepted: 05/09/2005] [Indexed: 11/15/2022]
Abstract
Isolates of bovine viral diarrhea virus (BVDV) are divided into cytopathic (cp) and noncytopathic (ncp) biotypes according to their effect on cultured cells. Calves persistently infected with ncp BVDV are known to develop lethal mucosal disease (MD) after superinfection by cp BVDV. Although the UV-irradiated supernatant of cp BVDV-infected cells has been reported to have no capacity to induce cell death, we found that it could enhance cell death through apoptosis. Up-regulation of tumor necrosis factor alpha (TNF-alpha) and inducible nitric oxide synthase (iNOS) mRNAs was detected specifically in cp BVDV-infected primary cell cultures. Suppression of TNF-alpha via antisense oligonucleotide transfection or incubation with a polyclonal antibody against TNF-alpha resulted in attenuation of apoptosis induced by cp BVDV, suggesting that TNF-alpha participates in apoptosis execution. Although TNF-alpha is one of the iNOS-inducible factors, the iNOS up-regulation was not regulated by TNF-alpha. And iNOS was revealed to serve as anti-apoptotic factor, contrary to our expectation. In addition, the expression level of both TNF-alpha and iNOS mRNAs in the ncp BVDV-infected cells was kept lower than that in the mock-infected cells, suggesting that ncp BVDV reduced or interfered with the factor triggering the expression of both mRNAs. These characteristic mRNA transcriptions would help to explain why BVDV acts differently in cells as well as in vivo, depending on its biotype. To elucidate viral factors inducing TNF-alpha and iNOS may be critical to understand the mechanism of MD development, which closely correlates with cp BVDV-induced apoptosis.
Collapse
Affiliation(s)
- D Yamane
- Department of Veterinary Microbiology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 113-8657, Japan
| | | | | | | | | |
Collapse
|