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Chang MG, Barbour TA, Bittner EA. Exploring Brain and Heart Interactions during Electroconvulsive Therapy with Point-of-Care Ultrasound. Med Sci (Basel) 2024; 12:17. [PMID: 38525771 PMCID: PMC11024754 DOI: 10.3390/medsci12020017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/05/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a procedure commonly used to treat a number of severe psychiatric disorders, including pharmacologic refractory depression, mania, and catatonia by purposefully inducing a generalized seizure that results in significant hemodynamic changes as a result of an initial transient parasympathetic response that is followed by a marked sympathetic response from a surge in catecholamine release. While the physiologic response of ECT on classic hemodynamic parameters such as heart rate and blood pressure has been described in the literature, real-time visualization of cardiac function using point-of-care ultrasound (POCUS) during ECT has never been reported. This study utilizes POCUS to examine cardiac function in two patients with different ages and cardiovascular risk profiles undergoing ECT. METHODS Two patients, a 74-year-old male with significant cardiovascular risks and a 23-year-old female with no significant cardiovascular risks presenting for ECT treatment, were included in this study. A portable ultrasound device was used to obtain apical four-chamber images of the heart before ECT stimulation, after seizure induction, and 2 min after seizure resolution to assess qualitative cardiac function. Two physicians with expertise in echocardiography reviewed the studies. Hemodynamic parameters, ECT settings, and seizure duration were recorded. RESULTS Cardiac standstill was observed in both patients during ECT stimulation. The 74-year-old patient with a significant cardiovascular risk profile exhibited a transient decline in cardiac function during ECT, while the 23-year-old patient showed no substantial worsening of cardiac function. These findings suggest that age and pre-existing cardiovascular conditions may influence the cardiac response to ECT. Other potential contributing factors to the cardiac effects of ECT include the parasympathetic and sympathetic responses, medication regimen, and seizure duration with ECT. This study also demonstrates the feasibility of using portable POCUS for real-time cardiac monitoring during ECT. CONCLUSION This study reports for the first time cardiac standstill during ECT stimulation visualized using POCUS imaging. In addition, it reports on the potential differential impact of ECT on cardiac function based on patient-specific factors such as age and cardiovascular risks that may have implications for ECT and perioperative anesthetic management and optimization.
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Affiliation(s)
- Marvin G. Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - Tracy A. Barbour
- Department of Psychiatry, Division of Behavioral Neurology and Neuropsychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
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2
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Chang MG, Berra L, Bittner EA. Bedside Ultrasound: The Silent Guardian for Upper Airway Assessment and Management. Semin Ultrasound CT MR 2024; 45:46-57. [PMID: 38056793 DOI: 10.1053/j.sult.2023.12.006] [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: 12/08/2023]
Abstract
Ultrasound evaluation of the upper airway has emerged as an essential instrument for clinicians, offering real-time assessment that can help to guide interventions and improve patient outcomes. This review aims to provide health care providers with a practical approach to performing ultrasound evaluation of the upper airway, covering basic physics relevant to upper airway ultrasound, the identification of key anatomical structures, and elucidating its various clinical applications, such as prediction of difficult airway, confirmation of endotracheal intubation, and guidance for surgical airway procedures and airway blocks. We also discuss evidence-based training programs, limitations, and future directions of ultrasound imaging of the upper airway.
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Affiliation(s)
- Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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3
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Ripoll JG, ElSaban M, Nabzdyk CS, Balakrishna A, Villavicencio MA, Calderon-Rojas RD, Ortoleva J, Chang MG, Bittner EA, Ramakrishna H. Obesity and Extracorporeal Membrane Oxygenation (ECMO): Analysis of Outcomes. J Cardiothorac Vasc Anesth 2024; 38:285-298. [PMID: 37953169 DOI: 10.1053/j.jvca.2023.10.025] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
Traditionally, patients with obesity have been deemed ineligible for extracorporeal life support (ELS) therapies such as extracorporeal membrane oxygenation (ECMO), given the association of obesity with chronic health conditions that contribute to increased morbidity and mortality. Nevertheless, a growing body of literature suggests the feasibility, efficacy, and safety of ECMO in the obese population. This review provides an in-depth analysis of the current literature assessing the effects of obesity on outcomes among patients supported with ECMO (venovenous [VV] ECMO in noncoronavirus disease 2019 and coronavirus disease 2019 acute respiratory distress syndrome, venoarterial [VA] ECMO, and combined VV and VA ECMO), offer a possible explanation of the current findings on the basis of the obesity paradox phenomenon, provides a framework for future studies addressing the use of ELS therapies in the obese patient population, and provides guidance from the literature for many of the challenges related to initiating, maintaining, and weaning ELS therapy in patients with obesity.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Mariam ElSaban
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Christoph S Nabzdyk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aditi Balakrishna
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Jamel Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Morais CCA, Alcala G, De Santis Santiago RR, Valsecchi C, Diaz E, Wanderley H, Fakhr BS, Di Fenza R, Gianni S, Foote S, Chang MG, Bittner EA, Carroll RW, Costa ELV, Amato MBP, Berra L. Pronation Reveals a Heterogeneous Response of Global and Regional Respiratory Mechanics in Patients With Acute Hypoxemic Respiratory Failure. Crit Care Explor 2023; 5:e0983. [PMID: 37795456 PMCID: PMC10547249 DOI: 10.1097/cce.0000000000000983] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVES Experimental models suggest that prone position and positive end-expiratory pressure (PEEP) homogenize ventral-dorsal ventilation distribution and regional respiratory compliance. However, this response still needs confirmation on humans. Therefore, this study aimed to assess the changes in global and regional respiratory mechanics in supine and prone positions over a range of PEEP levels in acute respiratory distress syndrome (ARDS) patients. DESIGN A prospective cohort study. PATIENTS Twenty-two intubated patients with ARDS caused by COVID-19 pneumonia. INTERVENTIONS Electrical impedance tomography and esophageal manometry were applied during PEEP titrations from 20 cm H2O to 6 cm H2O in supine and prone positions. MEASUREMENTS Global respiratory system compliance (Crs), chest wall compliance, regional lung compliance, ventilation distribution in supine and prone positions. MAIN RESULTS Compared with supine position, the maximum level of Crs changed after prone position in 59% of ARDS patients (n = 13), of which the Crs decreased in 32% (n = 7) and increased in 27% (n = 6). To reach maximum Crs after pronation, PEEP was changed in 45% of the patients by at least 4 cm H2O. After pronation, the ventilation and compliance of the dorsal region did not consistently change in the entire sample of patients, increasing specifically in a subgroup of patients who showed a positive change in Crs when transitioning from supine to prone position. These combined changes in ventilation and compliance suggest dorsal recruitment postpronation. In addition, the subgroup with increased Crs postpronation demonstrated the most pronounced difference between dorsal and ventral ventilation distribution from supine to prone position (p = 0.01), indicating heterogeneous ventilation distribution in prone position. CONCLUSIONS Prone position modifies global respiratory compliance in most patients with ARDS. Only a subgroup of patients with a positive change in Crs postpronation presented a consistent improvement in dorsal ventilation and compliance. These data suggest that the response to pronation on global and regional mechanics can vary among ARDS patients, with some patients presenting more dorsal lung recruitment than others.
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Affiliation(s)
- Caio C A Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Glasiele Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Roberta R De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Carlo Valsecchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Eduardo Diaz
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Hatus Wanderley
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Bijan Safaee Fakhr
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Stefano Gianni
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Sara Foote
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ryan W Carroll
- Division of Pediatric Critical Care, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA
| | - Eduardo L V Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Respiratory Care Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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5
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Xia M, Ma W, Zuo M, Deng X, Xue F, Battaglini D, Aggarwal V, Varrassi G, Cerny V, Di Giacinto I, Cataldo R, Ma D, Yamamoto T, Rekatsina M, De Cassai A, Carsetti A, Chang MG, Seet E, Davis DP, Irwin MG, Huang Y, Jiang H. Expert consensus on difficult airway assessment. Hepatobiliary Surg Nutr 2023; 12:545-566. [PMID: 37600997 PMCID: PMC10432292 DOI: 10.21037/hbsn-23-46] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/23/2023] [Indexed: 08/22/2023]
Abstract
Background Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room (OR) and non-operation room sites. There are no guidelines or expert consensus focused on the assessment of the difficult airway before, so this expert consensus is developed to provide guidance for airway assessment, making this process more standardized and accurate to reduce airway-related complications and improve safety. Methods Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology (CSA) met to discuss the first draft and then this was sent to 15 international experts for review, comment, and approval. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is used to determine the level of evidence and grade the strength of recommendations. The recommendations were revised through a three-round Delphi survey from experts. Results This expert consensus provides a comprehensive approach to airway assessment based on the medical history, physical examination, comprehensive scores, imaging, and new developments including transnasal endoscopy, virtual laryngoscopy, and 3D printing. In addition, this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway. Conclusions This consensus applies to anesthesiologists, critical care, and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.
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Affiliation(s)
- Ming Xia
- Department of Anesthesiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wuhua Ma
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Mingzhang Zuo
- Department of Anaesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Xiaoming Deng
- Department of Anesthesiology, Plastic Surgery Hospital, CAMS and PUMC, Beijing, China
| | - Fushan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Vivek Aggarwal
- Department of Conservative Dentistry & Endodontics, Jamia Millia Islamia, New Delhi, India
| | | | - Vladimir Cerny
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Ida Di Giacinto
- Unit of Anesthesia and Intensive Care, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Rita Cataldo
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Università Campus Bio-Medico of Rome, Roma, Italy
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, and Chelsea and Westminster Hospital, London, UK
| | - Toru Yamamoto
- Division of Dental Anesthesiology, Graduate School of Medicine and Dental Sciences, Niigata University, Niigata, Japan
| | - Martina Rekatsina
- Department of Anaesthesiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Alessandro De Cassai
- Institute of Anesthesia and Intensive Care Unit, University Hospital of Padua, Padua, Italy
| | - Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Marvin G. Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edwin Seet
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Daniel P. Davis
- Division of Emergency Medical Services, Logan Health, Kalispell, MT, USA
- Air Methods Corporation, Greenwood Park, CO, USA
| | - Michael G. Irwin
- Department of Anesthesiology, The University of Hong Kong, Hong Kong, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Hong Jiang
- Department of Anesthesiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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6
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Gibson LE, Mitchell JE, Bittner EA, Chang MG. An Assessment of Carotid Flow Time Using a Portable Handheld Ultrasound Device: The Ideal Tool for Guiding Intraoperative Fluid Management? Micromachines (Basel) 2023; 14:510. [PMID: 36984917 PMCID: PMC10055706 DOI: 10.3390/mi14030510] [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] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/17/2023] [Accepted: 02/17/2023] [Indexed: 06/18/2023]
Abstract
Volume resuscitation is a cornerstone of modern anesthesia care. Finding the right balance to avoid inadequate or excess volume administration is often difficult to clinically discern and can lead to negative consequences. Pulse pressure variation is often intraoperatively used to guide volume resuscitation; however, this requires an invasive arterial line and is generally only applicable to patients who are mechanically ventilated. Unfortunately, without a pulmonary artery catheter or another costly noninvasive device, performing serial measurements of cardiac output is challenging, time-consuming, and often impractical. Furthermore, noninvasive measures such as LVOT VTI require significant technical expertise as well as access to the chest, which may not be practical during and after surgery. Other noninvasive techniques such as bioreactance and esophageal Doppler require the use of costly single-use sensors. Here, we present a case report on the use of corrected carotid flow time (ccFT) from a portable, handheld ultrasound device as a practical, noninvasive, and technically straightforward method to assess fluid responsiveness in the perioperative period, as well as the inpatient and outpatient settings.
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Tankard KA, Sharifpour M, Chang MG, Bittner EA. Design and Implementation of Airway Response Teams to Improve the Practice of Emergency Airway Management. J Clin Med 2022; 11:6336. [PMID: 36362564 PMCID: PMC9656324 DOI: 10.3390/jcm11216336] [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: 10/01/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 09/11/2023] Open
Abstract
Emergency airway management (EAM) is a commonly performed procedure in the critical care setting. Despite clinical advances that help practitioners identify patients at risk for having a difficult airway, improved airway management tools, and algorithms that guide clinical decision-making, the practice of EAM is associated with significant morbidity and mortality. Evidence suggests that a dedicated airway response team (ART) can help mitigate the risks associated with EAM and provide a framework for airway management in acute settings. We review the risks and challenges related to EAM and describe strategies to improve patient care and outcomes via implementation of an ART.
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Affiliation(s)
- Kelly A. Tankard
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Milad Sharifpour
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA 90048, USA
| | - Marvin G. Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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Affiliation(s)
- Gabrielle A White-Dzuro
- Department of AnesthesiaCritical Care and Pain MedicineMassachusetts General HospitalBoston, Massachusetts
| | - Lauren E Gibson
- Department of AnesthesiaCritical Care and Pain MedicineMassachusetts General HospitalBoston, Massachusetts
| | - Lorenzo Berra
- Department of AnesthesiaCritical Care and Pain MedicineMassachusetts General HospitalBoston, Massachusetts
| | - Edward A Bittner
- Department of AnesthesiaCritical Care and Pain MedicineMassachusetts General HospitalBoston, Massachusetts
| | - Marvin G Chang
- Department of AnesthesiaCritical Care and Pain MedicineMassachusetts General HospitalBoston, Massachusetts
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9
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Abstract
Esophageal intubations are not an uncommon occurrence in prehospital settings, occurring as high as 17%. These "never events" are associated with significant morbidity and mortality especially when unrecognized or when there is delayed recognition. Here, we review the currently available techniques for confirming endotracheal tube intubation and their limitations, and present the case for the application of portable handheld point-of-care ultrasound as an emerging technology for detection of potentially unrecognized esophageal intubations such as during cardiac arrest. We also provide algorithms for confirmation of tracheal intubation.
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Affiliation(s)
- Gabrielle A White-Dzuro
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lauren E Gibson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Edward A Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Marvin G Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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10
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Singh J, Matern LH, Bittner EA, Chang MG. Characteristics of Simulation-Based Point-of-Care Ultrasound Education: A Systematic Review of MedEdPORTAL Curricula. Cureus 2022; 14:e22249. [PMID: 35186609 PMCID: PMC8849358 DOI: 10.7759/cureus.22249] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/05/2022] Open
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11
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Sakano T, Bittner EA, Chang MG. Severe COVID pneumonia and undetectable B cells after vaccination in patients previously treated with rituximab: a case series. Postgrad Med 2022; 134:239-243. [PMID: 35129061 DOI: 10.1080/00325481.2022.2037359] [Citation(s) in RCA: 1] [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] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The risk of developing severe COVID-19 illness despite completing vaccination for patients who have previously received immunosuppressive therapy is unclear. CASE PRESENTATION We present three patients who received rituximab for treatment of autoimmune disorders who subsequently developed severe COVID-19 pneumonia post-vaccination requiring intensive care unit admission and found to have undetectable B cells. DISCUSSION While there have been concerns about the effectiveness of COVID-19 vaccines in this patient cohort, this is the first case series to report development of severe COVID-19 illness after completing vaccination in those who previously received rituximab. Guidelines for the optimal timing of COVID-19 vaccination in relation to immunosuppressive therapy have been recently published, albeit after many patients in this subpopulation have already been vaccinated. CONCLUSION This case series brings attention to the limited humoral response to vaccines in patients treated with rituximab, highlights existing guidelines and their limitations, and raises future considerations about the potential benefits to testing vaccine responsiveness.
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Affiliation(s)
- Takashi Sakano
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Edward A Bittner
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marvin G Chang
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care and Pain Medicine General Hospital, Massachusetts General Hospital, Boston, Massachusetts, USA
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12
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Sullivan ZP, Zazzeron L, Berra L, Hess DR, Bittner EA, Chang MG. Noninvasive respiratory support for COVID-19 patients: when, for whom, and how? J Intensive Care 2022; 10:3. [PMID: 35033204 PMCID: PMC8760575 DOI: 10.1186/s40560-021-00593-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/26/2021] [Indexed: 12/14/2022] Open
Abstract
The significant mortality rate and prolonged ventilator days associated with invasive mechanical ventilation (IMV) in patients with severe COVID-19 have incited a debate surrounding the use of noninvasive respiratory support (NIRS) (i.e., HFNC, CPAP, NIV) as a potential treatment strategy. Central to this debate is the role of NIRS in preventing intubation in patients with mild respiratory disease and the potential beneficial effects on both patient outcome and resource utilization. However, there remains valid concern that use of NIRS may prolong time to intubation and lung protective ventilation in patients with more advanced disease, thereby worsening respiratory mechanics via self-inflicted lung injury. In addition, the risk of aerosolization with the use of NIRS has the potential to increase healthcare worker (HCW) exposure to the virus. We review the existing literature with a focus on rationale, patient selection and outcomes associated with the use of NIRS in COVID-19 and prior pandemics, as well as in patients with acute respiratory failure due to different etiologies (i.e., COPD, cardiogenic pulmonary edema, etc.) to understand the potential role of NIRS in COVID-19 patients. Based on this analysis we suggest an algorithm for NIRS in COVID-19 patients which includes indications and contraindications for use, monitoring recommendations, systems-based practices to reduce HCW exposure, and predictors of NIRS failure. We also discuss future research priorities for addressing unanswered questions regarding NIRS use in COVID-19 with the goal of improving patient outcomes.
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Affiliation(s)
- Zachary P Sullivan
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Luca Zazzeron
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Dean R Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, MA, Boston, USA.
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13
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Steinhorn R, Dalia AA, Bittner EA, Chang MG. Surgical pulmonary embolectomy on VA-ECMO. Respir Med Case Rep 2021; 34:101551. [PMID: 34868870 PMCID: PMC8626575 DOI: 10.1016/j.rmcr.2021.101551] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/07/2021] [Accepted: 11/08/2021] [Indexed: 11/01/2022] Open
Abstract
Surgical pulmonary embolectomy is a procedure that is often used to rescue patients with massive pulmonary embolism (PE) and circulatory collapse that have failed or may not be ideal candidates for other systemic and endovascular treatment modalities. This procedure typically involves a sternotomy and the use of cardiopulmonary bypass (CPB), which requires full systemic anticoagulation. Here, we report the case of a surgical pulmonary embolectomy performed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) rather than CPB to minimize systemic anticoagulation. The patient had suffered a cardiac arrest due to a saddle PE and required VA-ECMO which was complicated by a concomitant intracranial hemorrhage. The patient tolerated the surgical pulmonary embolectomy performed on VA-ECMO without procedure-related complications, and the ECMO support did not substantially complicate the technical performance of the procedure. In contrast to surgical pulmonary embolectomy performed on CPB, greater attention must be paid to volume status when performing the procedure on VA-ECMO since there is no blood reservoir. This case suggests cardiopulmonary support on ECMO as a viable strategy for surgical embolectomy in patients with unstable PEs in whom thrombolysis or full systemic anticoagulation are contraindicated.
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Key Words
- ACT, activated clotting time
- ASD, atrial septal defect
- CI, cardiac index
- CPB, cardiopulmonary bypass
- CT, computed tomography
- Cardiopulmonary bypass
- Case report
- EEG, electroencephalogram
- Extracorporeal membrane oxygenation
- ICU, intensive care unit
- LPA, left pulmonary artery
- MPA, main pulmonary artery
- MPAP, mean pulmonary artery pressure
- MRI, magnetic resonance imaging
- PA, pulmonary artery
- PE, pulmonary embolism
- PERT, pulmonary embolism response team
- PFO, patent foramen ovale
- PTT, partial thromboplastin time
- Pulmonary embolectomy
- Pulmonary embolism
- RPA, right pulmonary artery
- SDH, subdural hemorrhage
- TEE, transesophageal echocardiography
- TPA, tissue plasminogen activator
- VA-ECMO
- VA-ECMO, venoarterial extracorporeal membrane oxygenation
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Affiliation(s)
- Rachel Steinhorn
- Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine, United States
| | - Adam A Dalia
- Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine, United States
| | - Edward A Bittner
- Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine, United States
| | - Marvin G Chang
- Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine, United States
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14
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Angelini M, Pezhouman A, Savalli N, Chang MG, Steccanella F, Scranton K, Calmettes G, Ottolia M, Pantazis A, Karagueuzian HS, Weiss JN, Olcese R. Suppression of ventricular arrhythmias by targeting late L-type Ca2+ current. J Gen Physiol 2021; 153:212725. [PMID: 34698805 PMCID: PMC8552156 DOI: 10.1085/jgp.202012584] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 07/15/2021] [Accepted: 09/02/2021] [Indexed: 12/15/2022] Open
Abstract
Ventricular arrhythmias, a leading cause of sudden cardiac death, can be triggered by cardiomyocyte early afterdepolarizations (EADs). EADs can result from an abnormal late activation of L-type Ca2+ channels (LTCCs). Current LTCC blockers (class IV antiarrhythmics), while effective at suppressing EADs, block both early and late components of ICa,L, compromising inotropy. However, computational studies have recently demonstrated that selective reduction of late ICa,L (Ca2+ influx during late phases of the action potential) is sufficient to potently suppress EADs, suggesting that effective antiarrhythmic action can be achieved without blocking the early peak ICa,L, which is essential for proper excitation–contraction coupling. We tested this new strategy using a purine analogue, roscovitine, which reduces late ICa,L with minimal effect on peak current. Scaling our investigation from a human CaV1.2 channel clone to rabbit ventricular myocytes and rat and rabbit perfused hearts, we demonstrate that (1) roscovitine selectively reduces ICa,L noninactivating component in a human CaV1.2 channel clone and in ventricular myocytes native current, (2) the pharmacological reduction of late ICa,L suppresses EADs and EATs (early after Ca2+ transients) induced by oxidative stress and hypokalemia in isolated myocytes, largely preserving cell shortening and normal Ca2+ transient, and (3) late ICa,L reduction prevents/suppresses ventricular tachycardia/fibrillation in ex vivo rabbit and rat hearts subjected to hypokalemia and/or oxidative stress. These results support the value of an antiarrhythmic strategy based on the selective reduction of late ICa,L to suppress EAD-mediated arrhythmias. Antiarrhythmic therapies based on this idea would modify the gating properties of CaV1.2 channels rather than blocking their pore, largely preserving contractility.
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Affiliation(s)
- Marina Angelini
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Arash Pezhouman
- Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Nicoletta Savalli
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Marvin G Chang
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Federica Steccanella
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Kyle Scranton
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Guillaume Calmettes
- Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Michela Ottolia
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,University of California, Los Angeles Cardiovascular Theme, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Antonios Pantazis
- Division of Neurobiology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Wallenberg Center for Molecular Medicine, Linköping University, Linköping, Sweden
| | - Hrayr S Karagueuzian
- Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Cardiovascular Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - James N Weiss
- Department of Medicine (Cardiology), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Cardiovascular Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Riccardo Olcese
- Division of Molecular Medicine, Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Cardiovascular Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,University of California, Los Angeles Cardiovascular Theme, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.,Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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15
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Lindsay PJ, Rosovsky R, Bittner EA, Chang MG. Nuts and bolts of COVID-19 associated coagulopathy: the essentials for management and treatment. Postgrad Med 2021; 133:899-911. [PMID: 34470540 PMCID: PMC8442752 DOI: 10.1080/00325481.2021.1974212] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/26/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION COVID-19-associated coagulopathy (CAC) is a well-recognized hematologic complication among patients with severe COVID-19 disease, where macro- and micro-thrombosis can lead to multiorgan injury and failure. Major societal guidelines that have published on the management of CAC are based on consensus of expert opinion, with the current evidence available. As a result of limited studies, there are many clinical scenarios that are yet to be addressed, with expert opinion varying on a number of important clinical issues regarding CAC management. METHODS In this review, we utilize current societal guidelines to provide a framework for practitioners in managing their patients with CAC. We have also provided three clinical scenarios that implement important principles of anticoagulation in patients with COVID-19. CONCLUSION Overall, decisions should be made on acase by cases basis and based on the providers understanding of each patient's medical history, clinical course and perceived risk.
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Affiliation(s)
| | - Rachel Rosovsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marvin G Chang
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, Massachusetts, USA
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16
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Safaee Fakhr B, Di Fenza R, Gianni S, Wiegand SB, Miyazaki Y, Araujo Morais CC, Gibson LE, Chang MG, Mueller AL, Rodriguez-Lopez JM, Ackman JB, Arora P, Scott LK, Bloch DB, Zapol WM, Carroll RW, Ichinose F, Berra L. Inhaled high dose nitric oxide is a safe and effective respiratory treatment in spontaneous breathing hospitalized patients with COVID-19 pneumonia. Nitric Oxide 2021; 116:7-13. [PMID: 34400339 PMCID: PMC8361002 DOI: 10.1016/j.niox.2021.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/21/2021] [Accepted: 08/10/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Inhaled nitric oxide (NO) is a selective pulmonary vasodilator. In-vitro studies report that NO donors can inhibit replication of SARS-CoV-2. This multicenter study evaluated the feasibility and effects of high-dose inhaled NO in non-intubated spontaneously breathing patients with Coronavirus disease-2019 (COVID-19). METHODS This is an interventional study to determine whether NO at 160 parts-per-million (ppm) inhaled for 30 min twice daily might be beneficial and safe in non-intubated COVID-19 patients. RESULTS Twenty-nine COVID-19 patients received a total of 217 intermittent inhaled NO treatments for 30 min at 160 ppm between March and June 2020. Breathing NO acutely decreased the respiratory rate of tachypneic patients and improved oxygenation in hypoxemic patients. The maximum level of nitrogen dioxide delivered was 1.5 ppm. The maximum level of methemoglobin (MetHb) during the treatments was 4.7%. MetHb decreased in all patients 5 min after discontinuing NO administration. No adverse events during treatment, such as hypoxemia, hypotension, or acute kidney injury during hospitalization occurred. In our NO treated patients, one patient of 29 underwent intubation and mechanical ventilation, and none died. The median hospital length of stay was 6 days [interquartile range 4-8]. No discharged patients required hospital readmission nor developed COVID-19 related long-term sequelae within 28 days of follow-up. CONCLUSIONS In spontaneous breathing patients with COVID-19, the administration of inhaled NO at 160 ppm for 30 min twice daily promptly improved the respiratory rate of tachypneic patients and systemic oxygenation of hypoxemic patients. No adverse events were observed. None of the subjects was readmitted or had long-term COVID-19 sequelae.
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Affiliation(s)
- Bijan Safaee Fakhr
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Raffaele Di Fenza
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Stefano Gianni
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Steffen B Wiegand
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Yusuke Miyazaki
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Caio C Araujo Morais
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Lauren E Gibson
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Marvin G Chang
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Ariel L Mueller
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Josanna M Rodriguez-Lopez
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Jeanne B Ackman
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Division of Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Tinsley Harrison Tower, Suite 311, 1900 University Boulevard, Birmingham, AL, 35233, USA
| | - Louie K Scott
- Critical Care Medicine, Department of Medicine, LSU Health Shreveport, 1501 Kings Hwy, Shreveport, LA, 71103, USA
| | - Donald B Bloch
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Center for Immunology and Inflammatory Diseases and Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Warren M Zapol
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Ryan W Carroll
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Fumito Ichinose
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA; Respiratory Care Services, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
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17
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Abstract
INTRODUCTION The COVID-19 pandemic has brought unprecedented numbers of patients with acute respiratory distress to medical centers. Hospital systems require rapid adaptation to respond to the increased demand for airway management while ensuring high quality patient care and provider safety. There is limited literature detailing successful system-level approaches to adapt to the surge of COVID-19 patients requiring airway management. METHODS A deliberate system-level approach was used to expand a preexisting airway response service. Through a needs analysis (taking into account both existing resources and anticipated demands), we established priorities and solutions for the airway management challenges encountered during the pandemic. RESULTS During our COVID-19 surge (March 10, 2020, through May 26, 2020), there were 619 airway consults, and the COVID airway response team (CART) performed 341 intubations. Despite a 4-fold increase in intubations during the surge, there was no increase in cardiac arrests or surgical airways and no documented COVID-19 infections among the CART. CONCLUSIONS Our system-level approach successfully met the sudden escalation in demand in airway management incurred by the COVID-19 surge. The approach that addressed staffing needs prioritized provider protection and enhanced quality and safety monitoring may be adaptable to other institutions.
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18
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Gibson LE, Fenza RD, Lang M, Capriles MI, Li MD, Kalpathy-Cramer J, Little BP, Arora P, Mueller AL, Ichinose F, Bittner EA, Berra L, G. Chang M. Right Ventricular Strain Is Common in Intubated COVID-19 Patients and Does Not Reflect Severity of Respiratory Illness. J Intensive Care Med 2021; 36:900-909. [PMID: 33783269 PMCID: PMC8267080 DOI: 10.1177/08850666211006335] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Right ventricular (RV) dysfunction is common and associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19). In non-COVID-19 acute respiratory distress syndrome, RV dysfunction develops due to pulmonary hypoxic vasoconstriction, inflammation, and alveolar overdistension or atelectasis. Although similar pathogenic mechanisms may induce RV dysfunction in COVID-19, other COVID-19-specific pathology, such as pulmonary endothelialitis, thrombosis, or myocarditis, may also affect RV function. We quantified RV dysfunction by echocardiographic strain analysis and investigated its correlation with disease severity, ventilatory parameters, biomarkers, and imaging findings in critically ill COVID-19 patients. METHODS We determined RV free wall longitudinal strain (FWLS) in 32 patients receiving mechanical ventilation for COVID-19-associated respiratory failure. Demographics, comorbid conditions, ventilatory parameters, medications, and laboratory findings were extracted from the medical record. Chest imaging was assessed to determine the severity of lung disease and the presence of pulmonary embolism. RESULTS Abnormal FWLS was present in 66% of mechanically ventilated COVID-19 patients and was associated with higher lung compliance (39.6 vs 29.4 mL/cmH2O, P = 0.016), lower airway plateau pressures (21 vs 24 cmH2O, P = 0.043), lower tidal volume ventilation (5.74 vs 6.17 cc/kg, P = 0.031), and reduced left ventricular function. FWLS correlated negatively with age (r = -0.414, P = 0.018) and with serum troponin (r = 0.402, P = 0.034). Patients with abnormal RV strain did not exhibit decreased oxygenation or increased disease severity based on inflammatory markers, vasopressor requirements, or chest imaging findings. CONCLUSIONS RV dysfunction is common among critically ill COVID-19 patients and is not related to abnormal lung mechanics or ventilatory pressures. Instead, patients with abnormal FWLS had more favorable lung compliance. RV dysfunction may be secondary to diffuse intravascular micro- and macro-thrombosis or direct myocardial damage. TRIAL REGISTRATION National Institutes of Health #NCT04306393. Registered 10 March 2020, https://clinicaltrials.gov/ct2/show/NCT04306393.
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Affiliation(s)
- Lauren E. Gibson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Min Lang
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Martin I. Capriles
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew D. Li
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Brent P. Little
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Pankaj Arora
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ariel L. Mueller
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Fumito Ichinose
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marvin G. Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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19
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Southren DL, Nardone AD, Haastrup AA, Roberts RJ, Chang MG, Bittner EA. An examination of gastrointestinal absorption using the acetaminophen absorption test in critically ill patients with COVID-19: A retrospective cohort study. Nutr Clin Pract 2021; 36:853-862. [PMID: 34101267 PMCID: PMC8242470 DOI: 10.1002/ncp.10687] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Gastrointestinal (GI) dysfunction is prevalent in critically ill patients with coronavirus disease 2019 (COVID-19). The acetaminophen absorption test (AAT) has been previously described as a direct method for assessment of GI function. Our study determines whether the AAT can be used to assess GI function in critically ill COVID-19 patients, compared with traditional measures of GI function. DESIGN Retrospective observational study of critically ill patients with COVID-19. SETTING Three intensive care units at a tertiary care academic medical center. PATIENTS Twenty critically ill patients with COVID-19. INTERVENTIONS The results of AAT and traditional measures for assessing GI function were collected and compared. MEASUREMENTS AND MAIN RESULTS Among the study cohort, 55% (11 of 20) of patients had evidence of malabsorption by AAT. Interestingly, all patients with evidence of malabsorption by AAT had clinical evidence of bowel function, as indicated by stool output and low gastric residuals during the prior 24 h. When comparing patients with a detectable acetaminophen level (positive AAT) with those who had undetectable acetaminophen levels (negative AAT), radiologic evidence of ileus was less frequent (20 vs 88%; P = .03), tolerated tube-feed rates were higher (40 vs 10 ml/h; P =.01), and there was a trend toward lower gastric residual volumes (45 vs 830 ml; P =.11). CONCLUSION Malabsorption can occur in critically ill patients with COVID-19 despite commonly used clinical indicators of tube-feeding tolerance. The AAT provides a simple, rapid, and cost-effective mechanism by which enteral function can be efficiently assessed in COVID-19 patients.
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Affiliation(s)
- Daniel L Southren
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexa D Nardone
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adeniran A Haastrup
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marvin G Chang
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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20
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Balakrishna A, Walsh EC, Hamidi A, Berg S, Austin D, Pino RM, Hanidziar D, Chang MG, Bittner EA. An examination of sedation requirements and practices for mechanically ventilated critically ill patients with COVID-19. Am J Health Syst Pharm 2021; 78:1952-1961. [PMID: 33993212 PMCID: PMC8194529 DOI: 10.1093/ajhp/zxab202] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Preliminary reports suggest that critically ill patients with coronavirus disease 2019 (COVID-19) infection requiring mechanical ventilation may have markedly increased sedation needs compared with non-mechanically ventilated patients. We conducted a study to examine sedative use for this patient population within multiple intensive care units (ICUs) of a large academic medical center. METHODS A retrospective, single-center cohort study of sedation practices for critically ill patients with COVID-19 during the first 10 days of mechanical ventilation was conducted in 8 ICUs at Massachusetts General Hospital, Boston, MA. The study population was a sequential cohort of 86 critically ill, mechanically ventilated patients with COVID-19. Data characterizing the sedative medications, doses, drug combinations, and duration of administration were collected daily and compared to published recommendations for sedation of critically ill patients without COVID-19. The associations between drug doses, number of drugs administered, baseline patient characteristics, and inflammatory markers were investigated. RESULTS Among the study cohort, propofol and hydromorphone were the most common initial drug combination, with these medications being used on a given day in up to 100% and 88% of patients, respectively. The doses of sedative and analgesic infusions increased for patients over the first 10 days, reaching or exceeding the upper limits of published dosage guidelines for propofol (48% of patients), dexmedetomidine (29%), midazolam (7.7%), ketamine (32%), and hydromorphone (38%). The number of sedative and analgesic agents simultaneously administered increased over time for each patient, with more than 50% of patients requiring 3 or more agents by day 2. Compared with patients requiring 3 or fewer agents, as a group patients requiring more than 3 agents were of younger age, had an increased body mass index, increased serum ferritin and lactate dehydrogenase concentrations, had a lower PaO2:FIO2 (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen), and were more likely to receive neuromuscular blockade. CONCLUSION Our study confirmed the clinical impression of elevated sedative use in critically ill, mechanically ventilated patients with COVID-19 relative to guideline-recommended sedation practices in other critically ill populations.
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Affiliation(s)
- Aditi Balakrishna
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elisa C Walsh
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Arzo Hamidi
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Sheri Berg
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Austin
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard M Pino
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dusan Hanidziar
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin G Chang
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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21
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Abstract
The use of ultrasound guidance for the placement of difficult IVs, arterial lines, and central venous access has become the standard of care. While imaging quality has improved over the last two decades, the lack of affordability, availability, and training have been major limitations in its routine clinical use. We detail the first reported use of biplane imaging using a portable ultrasound probe for difficult vascular access to increase first past success, efficiency, safety, and sterility during the coronavirus disease 2019 (COVID-19) pandemic.
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Affiliation(s)
- David Convissar
- Anesthesiology and Critical Care, Massachusetts General Hospital, Boston, USA
| | - Edward A Bittner
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Marvin G Chang
- Anesthesiology and Critical Care, Massachusetts General Hospital, Boston, USA
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22
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White-Dzuro G, Gibson LE, Zazzeron L, White-Dzuro C, Sullivan Z, Diiorio DA, Low SA, Chang MG, Bittner EA. Multisystem effects of COVID-19: a concise review for practitioners. Postgrad Med 2021; 133:20-27. [PMID: 32921198 PMCID: PMC7651182 DOI: 10.1080/00325481.2020.1823094] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023]
Abstract
While COVID-19 has primarily been characterized by the respiratory impact of viral pneumonia, it affects every organ system and carries a high consequent risk of death in critically ill patients. Higher sequential organ failure assessment (SOFA) scores have been associated with increased mortality in patients critically ill patients with COVID-19. It is important that clinicians managing critically ill COVID-19 patients be aware of the multisystem impact of the disease so that care can be focused on the prevention of end-organ injuries to potentially improve clinical outcomes. We review the multisystem complications of COVID-19 and associated treatment strategies to improve the care of critically ill COVID-19 patients.
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Affiliation(s)
- Gabrielle White-Dzuro
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren E. Gibson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Luca Zazzeron
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Colin White-Dzuro
- School of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Zachary Sullivan
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daren A. Diiorio
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sarah A. Low
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marvin G. Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A. Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Gibson LE, White-Dzuro GA, Lindsay PJ, Berg SM, Bittner EA, Chang MG. Ensuring competency in focused cardiac ultrasound: a systematic review of training programs. J Intensive Care 2020; 8:93. [PMID: 33308314 PMCID: PMC7730755 DOI: 10.1186/s40560-020-00503-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/27/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Focused cardiac ultrasound (FoCUS) is a valuable skill for rapid assessment of cardiac function and volume status. Despite recent widespread adoption among physicians, there is limited data on the optimal training methods for teaching FoCUS and metrics for determining competency. We conducted a systematic review to gain insight on the optimal training strategies, including type and duration, that would allow physicians to achieve basic competency in FoCUS. METHODS Embase, PubMed, and Cochrane Library databases were searched from inception to June 2020. Included studies described standardized training programs for at least 5 medical students or physicians on adult FoCUS, followed by an assessment of competency relative to an expert. Data were extracted, and bias was assessed for each study. RESULTS Data were extracted from 23 studies on 292 learners. Existing FoCUS training programs remain varied in duration and type of training. Learners achieved near perfect agreement (κ > 0.8) with expert echocardiographers on detecting left ventricular systolic dysfunction and pericardial effusion with 6 h each of didactics and hands-on training. Substantial agreement (κ > 0.6) on could be achieved in half this time. CONCLUSION A short training program will allow most learners to achieve competency in detecting left ventricular systolic dysfunction and pericardial effusion by FoCUS. Additional training is necessary to ensure skill retention, improve efficiency in image acquisition, and detect other pathologies.
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Affiliation(s)
- Lauren E Gibson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA.
| | - Gabrielle A White-Dzuro
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
| | - Patrick J Lindsay
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
| | - Sheri M Berg
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street GRB 444, Boston, MA, 02114, USA
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Lindsay PJ, Gibson LE, Bittner EA, Berg S, Chang MG. Sodium-glucose cotransporter-2 (SGLT2) inhibitor-induced euglycemic diabetic ketoacidosis complicating the perioperative management of a patient with type 2 diabetes mellitus (T2DM) and Fournier's gangrene: A case report. Int J Surg Case Rep 2020; 77:463-466. [PMID: 33395826 PMCID: PMC7695895 DOI: 10.1016/j.ijscr.2020.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/04/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
This case highlights two serious side effects of empagliflozin occurring concurrently. Those being diabetic ketoacidosis and Fournier’s gangrene. Diabetic ketoacidosis is an important cause of perioperative high anion gap metabolic acidosis in the context of SGLT2 inhibitors and needs to be carefully managed. SGLT2 inhibitors should be held up to 48 h prior to surgery to minimize the risk of diabetic ketoacidosis perioperatively.
Introduction Sodium glucose cotransporter-2 inhibitors (SGLT2) are an increasingly administered class of medication used to lower blood glucose levels in patients with type 2 diabetes mellitus. Diabetic ketoacidosis (DKA) and Fournier’s gangrene are rare, but potentially catastrophic side effects of SGLT2 inhibitors. This manuscript reports a case of both DKA and Fournier’s gangrene in the context of SGLT2 inhibitor use. Presentation of case A 51-year-old morbidly obese man with hypertension and poorly controlled Type 2 Diabetes Mellitus presented to the emergency department with a clinical presentation consistent with Fournier’s gangrene. He was promptly taken to the operating room by the urology team where he had extensive debridement of the perineum and abdomen. Intra-operatively he was found to have DKA, which was managed appropriately. The acidosis and Fournier’s gangrene were deemed a likely side effect of SGLT2 inhibitor use. After a thirty-day hospital admission, the patient was discharged to a rehabilitation facility where he is progressing well. His SGLT2 inhibitor was discontinued upon admission to hospital. Discussion Perioperative providers should have a high index of suspicion for diabetic ketoacidosis (DKA) and Fournier’s gangrene in patients prescribed SGLT2 inhibitors. Prompt treatment of DKA through correction of underlying triggers, aggressive fluid resuscitation, insulin to close the anion gap, and appropriate potassium repletion is vital to optimize patient outcomes. Conclusion The use of SGLT2 inhibitors among surgical populations is increasing. This case highlights the importance of being aware of the mechanism and side effects of SGLT2 inhibitors, and the management of DKA.
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Affiliation(s)
- Patrick J Lindsay
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA.
| | - Lauren E Gibson
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA
| | - Sheri Berg
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA
| | - Marvin G Chang
- Department of Anesthesia Critical Care and Pain, Massachusetts General Hospital, Boston, MA, USA
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Safaee Fakhr B, Araujo Morais CC, De Santis Santiago RR, Di Fenza R, Gibson LE, Restrepo PA, Chang MG, Bittner EA, Pinciroli R, Fintelmann FJ, Kacmarek RM, Berra L. Bedside monitoring of lung perfusion by electrical impedance tomography in the time of COVID-19. Br J Anaesth 2020; 125:e434-e436. [PMID: 32859359 PMCID: PMC7413127 DOI: 10.1016/j.bja.2020.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/02/2020] [Indexed: 02/07/2023] Open
Affiliation(s)
- Bijan Safaee Fakhr
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Caio C Araujo Morais
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Roberta R De Santis Santiago
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Raffaele Di Fenza
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lauren E Gibson
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Paula A Restrepo
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Marvin G Chang
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Edward A Bittner
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Riccardo Pinciroli
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Florian J Fintelmann
- Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Robert M Kacmarek
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA.
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Affiliation(s)
- Lauren E Gibson
- Division of Cardiac Anesthesia and Critical Care, Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,
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27
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Austin DR, Chang MG, Bittner EA. Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management. Chest 2020; 159:1155-1165. [PMID: 32971075 DOI: 10.1016/j.chest.2020.09.083] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [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: 05/17/2020] [Revised: 08/27/2020] [Accepted: 09/13/2020] [Indexed: 12/22/2022] Open
Abstract
Emergency airway management (EAM) is associated with a high rate of complications, morbidity, and mortality. Handheld point-of-care ultrasound shows promise as an emerging technology to facilitate rapid screening for difficult laryngoscopy, identify the cricothyroid membrane for potential cricothyroidotomy, and assess for increased aspiration risk, as well as provide confirmation of proper endotracheal tube positioning. This review summarizes the available evidence for the use of point-of-care ultrasound in EAM, provides an algorithm to facilitate its incorporation into existing EAM practice to improve patient safety, and serves as a framework for future validation studies.
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Affiliation(s)
- Daniel R Austin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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28
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Flaczyk A, Rosovsky RP, Reed CT, Bankhead-Kendall BK, Bittner EA, Chang MG. Comparison of published guidelines for management of coagulopathy and thrombosis in critically ill patients with COVID 19: implications for clinical practice and future investigations. Crit Care 2020; 24:559. [PMID: 32938471 PMCID: PMC7492793 DOI: 10.1186/s13054-020-03273-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/02/2020] [Indexed: 01/14/2023]
Abstract
Critically ill patients with COVID-19 are at increased risk for thrombotic complications which has led to an intense debate surrounding their anticoagulation management. In the absence of data from randomized controlled clinical trials, a number of consensus guidelines and recommendations have been published to facilitate clinical decision-making on this issue. However, substantive differences exist between these guidelines which can be difficult for clinicians. This review briefly summarizes the major societal guidelines and compares their similarities and differences. A common theme in all of the recommendations is to take an individualized approach to patient management and a call for prospective randomized clinical trials to address important anticoagulation issues in this population.
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Affiliation(s)
- Adam Flaczyk
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - Clay T Reed
- Division of Hematology and Oncology, National Institutes of Health, Bethesda, MD, USA
| | - Brittany K Bankhead-Kendall
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A Bittner
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Marvin G Chang
- Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA.
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29
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Sakano T, Bittner EA, Chang MG, Berra L. Above and beyond: biofilm and the ongoing search for strategies to reduce ventilator-associated pneumonia (VAP). Crit Care 2020; 24:510. [PMID: 32811553 PMCID: PMC7432533 DOI: 10.1186/s13054-020-03234-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 08/09/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Takashi Sakano
- Division of Critical Care, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A Bittner
- Division of Critical Care, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marvin G Chang
- Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Lorenzo Berra
- Division of Critical Care, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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30
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Gibson LE, Bittner EA, Chang MG. Handheld ultrasound devices: An emerging technology to reduce viral spread during the Covid-19 pandemic. Am J Infect Control 2020; 48:968-969. [PMID: 32512082 PMCID: PMC7273157 DOI: 10.1016/j.ajic.2020.05.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 01/24/2023]
Affiliation(s)
- Lauren E Gibson
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
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31
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Chang MG, Bittner EA, Dalia AA. Perioperative TTE Service: Developing a Roadmap for Success. J Cardiothorac Vasc Anesth 2020; 35:233-234. [PMID: 32873487 DOI: 10.1053/j.jvca.2020.07.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Marvin G Chang
- Department of Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Edward A Bittner
- Department of Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Abstract
This review highlights the ultrasound findings reported from a number of studies and case reports and discusses the unifying findings from coronavirus disease (COVID-19) patients and from the avian (H7N9) and H1N1 influenza epidemics. We discuss the potential role for portable point-of-care ultrasound (PPOCUS) as a safe and effective bedside option in the initial evaluation, management, and monitoring of disease progression in patients with confirmed or suspected COVID-19 infection.
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Affiliation(s)
- David L Convissar
- From the Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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33
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Xi AS, Chang MG, Bittner EA. Rapid establishment of an ICU using anesthesia ventilators during COVID-19 pandemic: lessons learned. Crit Care 2020; 24:388. [PMID: 32605580 PMCID: PMC7326394 DOI: 10.1186/s13054-020-03107-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/17/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Amanda S Xi
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin G Chang
- Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Edward A Bittner
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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34
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Sullivan EH, Gibson LE, Berra L, Chang MG, Bittner EA. In-hospital airway management of COVID-19 patients. Crit Care 2020; 24:292. [PMID: 32503600 PMCID: PMC7274058 DOI: 10.1186/s13054-020-03018-x] [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] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/25/2020] [Indexed: 01/08/2023]
Abstract
Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with suspected or confirmed COVID-19 infection.
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Affiliation(s)
- Elise H Sullivan
- Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren E Gibson
- Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lorenzo Berra
- Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin G Chang
- Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. .,Division of Cardiac Anesthesia and Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA.
| | - Edward A Bittner
- Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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35
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Arkin N, Krishnan K, Chang MG, Bittner EA. Nutrition in critically ill patients with COVID-19: Challenges and special considerations. Clin Nutr 2020; 39:2327-2328. [PMID: 32425291 PMCID: PMC7227546 DOI: 10.1016/j.clnu.2020.05.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Nicole Arkin
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin G Chang
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Edward A Bittner
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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36
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Convissar D, Chang CY, Choi WE, Chang MG, Bittner EA. The Vacuum Assisted Negative Pressure Isolation Hood (VANISH) System: Novel Application of the Stryker Neptune™ Suction Machine to Create COVID-19 Negative Pressure Isolation Environments. Cureus 2020; 12:e8126. [PMID: 32426202 PMCID: PMC7228800 DOI: 10.7759/cureus.8126] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/13/2020] [Indexed: 01/25/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) may remain viable in the air for up to three hours, placing health care workers in close proximity to aerosolizing procedures particularly at high risk for infection. This combined with the drastic shortage of negative pressure rooms hospitals worldwide has led to the rapid innovation of novel biohazard isolation hoods, which can be adapted to create negative pressure isolation environments around the patient's airway using the hospital wall suction, which carries many limitations, including weaker suction capabilities, single patient use, and immobility. Here, we report our Vacuum Assisted Negative Pressure Isolation Hood (VANISH) system that uses a mobile and readily available in most hospital operating rooms Stryker Neptune™ (Stryker Corporation, Kalamazoo, Michigan) high-powered suction system to more effectively create a negative pressure biohazard isolation environment. VANISH has been utilized regularly in an anesthesia practice of 30+ providers and, to date, there have been no documented COVID-19 infections.
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Affiliation(s)
- David Convissar
- Anesthesiology and Critical Care, Massachusetts General Hospital, Boston, USA
| | | | - Wonjae E Choi
- Anesthesiology, Mercy General Hospital, Sacramento, USA
| | - Marvin G Chang
- Anesthesiology and Critical Care, Massachusetts General Hospital, Boston, USA
| | - Edward A Bittner
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
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37
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Convissar D, Berra L, Chang MG, Bittner EA. Personal Protective Equipment N95 Facemask Shortage Quick Fix: The Modified Airway From VEntilatoR Circuit (MAVerIC). Cureus 2020; 12:e7914. [PMID: 32440384 PMCID: PMC7237167 DOI: 10.7759/cureus.7914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We are in a crisis where healthcare providers on the frontlines are running out of the appropriate personal protective equipment including N95 masks and power air-purifying respirators. Here, we propose a makeshift filter mask that we call the Modified Airway from VEntilatoR Circuit (MAVerIC) that can be assembled within seconds using widely available supplies routinely utilized by anesthesia providers in the operating room to provide practitioners on the frontlines with the high standard of protection of a N95 mask during the coronavirus disease 2019 (COVID-19) pandemic, and can be easily quantitatively “fit tested” to ensure no significant leak to optimize safety and efficacy.
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Affiliation(s)
- David Convissar
- Anesthesiology and Critical Care, Massachusetts General Hospital, Boston, USA
| | - Lorenzo Berra
- Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Marvin G Chang
- Anesthesiology and Critical Care, Massachusetts General Hospital, Boston, USA
| | - Edward A Bittner
- Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, USA
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38
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Chang MG, Miller M, Dalia AA. Intraoperative Management of Left Ventricular Assist Device Explantation: Complications and Lessons Learned. J Cardiothorac Vasc Anesth 2019; 34:1002-1004. [PMID: 31787431 DOI: 10.1053/j.jvca.2019.10.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/04/2019] [Accepted: 10/11/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Marvin G Chang
- Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Monica Miller
- Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Pain Medicine, and Critical Care, The Massachusetts General Hospital, Harvard Medical School, Boston, MA
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39
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Chang MG, de Lange E, Calmettes G, Garfinkel A, Qu Z, Weiss JN. Pro- and antiarrhythmic effects of ATP-sensitive potassium current activation on reentry during early afterdepolarization-mediated arrhythmias. Heart Rhythm 2012; 10:575-82. [PMID: 23246594 DOI: 10.1016/j.hrthm.2012.12.017] [Citation(s) in RCA: 12] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Under conditions promoting early afterdepolarizations (EADs), ventricular tissue can become bi-excitable, that is, capable of wave propagation mediated by either the Na current (INa) or the L-type calcium current (ICa,L), raising the possibility that ICa,L-mediated reentry may contribute to polymorphic ventricular tachycardia (PVT) and torsades de pointes. ATP-sensitive K current (IKATP) activation suppresses EADs, but the effects on ICa,L-mediated reentry are unknown. OBJECTIVE To investigate the effects of IKATP activation on ICa,L-mediated reentry. METHODS We performed optical voltage mapping in cultured neonatal rat ventricular myocyte monolayers exposed to BayK8644 and isoproterenol. The effects of pharmacologically activating IKATP with pinacidil were analyzed. RESULTS In 13 monolayers with anatomic ICa,L-mediated reentry around a central obstacle, pinacidil (50 μM) converted ICa,L-mediated reentry to INa-mediated reentry. In 33 monolayers with functional ICa,L-mediated reentry (spiral waves), pinacidil terminated reentry in 17, converted reentry into more complex INa-mediated reentry resembling fibrillation in 12, and had no effect in 4. In simulated 2-dimensional bi-excitable tissue in which ICa,L- and INa-mediated wave fronts coexisted, slow IKATP activation (over minutes) reliably terminated rotors but rapid IKATP activation (over seconds) often converted ICa,L-mediated reentry to INa-mediated reentry resembling fibrillation. CONCLUSIONS IKATP activation can have proarrhythmic effects on EAD-mediated arrhythmias if ICa,L-mediated reentry is present.
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Affiliation(s)
- Marvin G Chang
- Department of Medicine (Cardiology), David Geffen School of Medicine at University of California, Los Angeles, CA 90095, USA
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40
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Chang MG, Sato D, de Lange E, Lee JH, Karagueuzian HS, Garfinkel A, Weiss JN, Qu Z. Bi-stable wave propagation and early afterdepolarization-mediated cardiac arrhythmias. Heart Rhythm 2011; 9:115-22. [PMID: 21855520 DOI: 10.1016/j.hrthm.2011.08.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 08/07/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND In normal atrial and ventricular tissue, the electrical wavefronts are mediated by the fast sodium current (I(Na)), whereas in sinoatrial and atrioventricular nodal tissue, conduction is mediated by the slow L-type calcium current (I(Ca,L)). However, it has not been shown whether the same tissue can exhibit both the I(Na)-mediated and the I(Ca,L)-mediated conduction. OBJECTIVE This study sought to test the hypothesis that bi-stable cardiac wave conduction, mediated by I(Na) and I(Ca,L), respectively, can occur in the same tissue under conditions promoting early afterdepolarizations (EADs), and to study how this novel wave dynamics is related to the mechanisms of EAD-mediated arrhythmias. METHODS Computer models of two-dimensional (2D) tissue with a physiologically detailed action potential model were used to study the bi-stable wave dynamics. Theoretical predictions were tested experimentally by optical mapping in neonatal rat ventricular myocyte monolayers. RESULTS In the same 2D homogeneous tissue, we could induce spiral waves that are mediated by either I(Na) or I(Ca,L) under conditions in which the action potential model exhibited EADs. This bi-stable wave propagation behavior was similar to bi-stability shown in many other nonlinear systems. Because the bi-stable states are also excitable, we call this novel behavior bi-excitability. In a 2D heterogeneous tissue, the I(Ca,L)-mediated spiral wave meanders, giving rise to a twisting electrocardiographic QRS axis, resembling torsades de pointes, whereas the coexistence and interplay between the I(Na)-mediated wavefronts and I(Ca,L)-mediated wavefronts give rise to polymorphic ventricular tachycardia. We also present experimental evidence for bi-excitability under EAD-promoting conditions in neonatal rat ventricular myocyte monolayers exposed to BayK8644 and isoproterenol. CONCLUSION Under EAD-prone conditions, both I(Na)-mediated conduction and I(Ca,L)-mediated conduction can occur in the same tissue. These novel wave dynamics may be responsible for certain EAD-mediated arrhythmias, such as torsades de pointes and polymorphic ventricular tachycardia.
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Affiliation(s)
- Marvin G Chang
- Department of Medicine (Cardiology), David Geffen School of Medicine at University of California, Los Angeles, California 90095, USA
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Chen F, De Diego C, Chang MG, McHarg JL, John S, Klitzner TS, Weiss JN. Atrioventricular conduction and arrhythmias at the initiation of beating in embryonic mouse hearts. Dev Dyn 2010; 239:1941-9. [PMID: 20549739 DOI: 10.1002/dvdy.22319] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
To investigate cardiac physiology at the onset of heart beating in embryonic mouse hearts, we performed optical imaging of membrane potential (Vm) and/or intracellular calcium (Ca(i)). Action potentials and Ca(i) transients were detected in approximately 50% of mouse embryo hearts at E8.5, but in all hearts at E9.0, indicating that beating typically starts between E8-E9. Beating was eliminated by Ca channel blocker nifedipine and the I(f) blocker ZD7288, unaffected by tetrodotoxin and only mildly depressed by disabling sarcoplasmic (SR) and endoplasmic (ER) reticulum Ca cycling. From E8.5 to E10, conduction velocity increased from 0.2-1 mm/s to >5 mm/s in first ventricular and then atrial tissue, while remaining slow in other areas. Arrhythmias included atrioventricular reentry induced by adenosine. In summary, at the onset of beating, I(f)-dependent pacemaking drives both AP propagation and Ca(i) transient generation through activation of voltage-dependent Ca channels. Na channels and intracellular Ca cycling have minor roles.
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Affiliation(s)
- Fuhua Chen
- UCLA Cardiovascular Research Laboratory, David Geffen School of Medicine, University of California-Los Angeles, 675 Charles Young Drive South, Los Angeles, CA 90095, USA
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Chang MG, Zhang Y, Chang CY, Xu L, Emokpae R, Tung L, Marbán E, Abraham MR. Spiral waves and reentry dynamics in an in vitro model of the healed infarct border zone. Circ Res 2009; 105:1062-71. [PMID: 19815825 DOI: 10.1161/circresaha.108.176248] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [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: 11/16/2022]
Abstract
RATIONALE Reentry underlies most ventricular tachycardias (VTs) seen postmyocardial infarction (MI). Mapping studies reveal that the majority of VTs late post-MI arise from the infarct border zone (IBZ). OBJECTIVE To investigate reentry dynamics and the role of individual ion channels on reentry in in vitro models of the "healed" IBZ. METHODS AND RESULTS We designed in vitro models of the healed IBZ by coculturing skeletal myotubes with neonatal rat ventricular myocytes and performed optical mapping at high temporal and spatial resolution. In culture, neonatal rat ventricular myocytes mature to form striated myocytes and electrically uncoupled skeletal myotubes simulate fibrosis seen in the healed IBZ. High resolution mapping revealed that skeletal myotubes produced localized slowing of conduction velocity (CV), increased dispersion of CV and directional-dependence of activation delay without affecting myocyte excitability. Reentry was easily induced by rapid pacing in cocultures; treatment with lidocaine, a Na(+) channel blocker, significantly decreased reentry rate and CV, increased reentry path length and terminated 30% of reentrant arrhythmias (n=18). In contrast, nitrendipine, an L-type Ca(2+) channel blocker terminated 100% of reentry episodes while increasing reentry cycle length and path length and decreasing reentry CV (n=16). K(+) channel blockers increased reentry action potential duration but infrequently terminated reentry (n=12). CONCLUSIONS Cocultures reproduce several architectural and electrophysiological features of the healed IBZ. Reentry termination by L-type Ca(2+) channel, but not Na(+) channel, blockers suggests a greater Ca(2+)-dependence of propagation. These results may help explain the low efficacy of pure Na(+) channel blockers in preventing and terminating clinical VTs late after MI.
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Affiliation(s)
- Marvin G Chang
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD 21205, USA
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Lin JW, Garber L, Qi YR, Chang MG, Cysyk J, Tung L. Region of slowed conduction acts as core for spiral wave reentry in cardiac cell monolayers. Am J Physiol Heart Circ Physiol 2008; 294:H58-65. [DOI: 10.1152/ajpheart.00631.2007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Pathophysiological heterogeneity in cardiac tissue is related to the occurrence of arrhythmias. Of importance are regions of slowed conduction, which have been implicated in the formation of conduction block and reentry. Experimentally, it has been a challenge to produce local heterogeneity in a manner that is both reversible and well controlled. Consequently, we developed a dual-zone superfusion chamber that can dynamically create a small (5 mm) central island of heterogeneity in cultured cardiac cell monolayers. Three different conditions were studied to explore the effect of regionally slowed conduction on wave propagation and reentry: depolarization by elevated extracellular potassium, sodium channel inhibition with lidocaine, and cell-cell decoupling with palmitoleic acid. Using optical mapping of transmembrane voltage, we found that the central region of slowed conduction always served as the core region around which a spiral wave formed and then revolved following a period of rapid pacing. Because of the localized slowing in the core region, we observed experimentally for the first time an S shape of the spiral wave front near its tip. These results indicate that a small region of slowed conduction can play a crucial role in the formation, anchoring, and modulation of reentrant spiral waves.
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Chang MG, Tung L, Sekar RB, Chang CY, Cysyk J, Dong P, Marbán E, Abraham MR. Proarrhythmic Potential of Mesenchymal Stem Cell Transplantation Revealed in an In Vitro Coculture Model. Circulation 2006; 113:1832-41. [PMID: 16606790 DOI: 10.1161/circulationaha.105.593038] [Citation(s) in RCA: 180] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background—
Mesenchymal stem cells (MSCs) are bone marrow stromal cells that are in phase 1 clinical studies of cellular cardiomyoplasty. However, the electrophysiological effects of MSC transplantation have not been studied. Although improvement of ventricular function would represent a positive outcome of MSC transplantation, focal application of stem cells has the potential downside of creating inhomogeneities that may predispose the heart to reentrant arrhythmias. In the present study we use an MSC and neonatal rat ventricular myocyte (NRVM) coculture system to investigate potential proarrhythmic consequences of MSC transplantation into the heart.
Methods and Results—
Human MSCs were cocultured with NRVMs in ratios of 1:99, 1:9, and 1:4 and optically mapped. We found that conduction velocity was decreased in cocultures compared with controls, but action potential duration (APD
80
) was not affected. Reentrant arrhythmias were induced in 86% of cocultures containing 10% and 20% MSCs (n=36) but not in controls (n=7) or cocultures containing only 1% MSCs (n=4). Immunostaining, Western blot, and dye transfer revealed the presence of functional gap junctions involving MSCs.
Conclusions—
Our results suggest that mixtures of MSCs and NRVMs can produce an arrhythmogenic substrate. The mechanism of reentry is probably increased tissue heterogeneity resulting from electric coupling of inexcitable MSCs with myocytes.
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Affiliation(s)
- Marvin G Chang
- Division of Cardiology, Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, MD, USA
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Abstract
Skeletal myoblasts are an attractive cell type for transplantation because they are autologous and resistant to ischemia. However, clinical trials of myoblast transplantation in heart failure have been plagued by ventricular tachyarrhythmias and sudden cardiac death. The pathogenesis of these arrhythmias is poorly understood, but may be related to the fact that skeletal muscle cells, unlike heart cells, are electrically isolated by the absence of gap junctions. Using a novel in vitro model of myoblast transplantation in cardiomyocyte monolayers, we investigated the mechanisms of transplant-associated arrhythmias. Cocultures of human skeletal myoblasts and rat cardiomyocytes resulted in reentrant arrhythmias (spiral waves) that reproduce the features of ventricular tachycardia seen in patients receiving myoblast transplants. These arrhythmias could be terminated by nitrendipine, an l-type calcium channel blocker, but not by the Na channel blocker lidocaine. Genetic modification of myoblasts to express the gap junction protein connexin43 decreased arrhythmogenicity in cocultures, suggesting a specific means for increasing the safety (and perhaps the efficacy) of myoblast transplantation in patients.
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Affiliation(s)
- M Roselle Abraham
- Institute of Molecular Cardiobiology, Johns Hopkins University, Carnegie 568, 600 N Wolfe St, Baltimore, MD 21205, USA
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