[Show abstract][Hide abstract] ABSTRACT: Objectives. Despite the increasing utilization of point-of-care critical care ultrasonography (CCUS), standards establishing competency for its use are lacking. The purpose of this study was to evaluate the effectiveness of a 2-day CCUS course implementation on ultrasound-naïve critical care medicine (CCM) fellows. Methods. Prospective evaluation of the impact of a two-day CCUS course on eight CCM fellows' attitudes, proficiency, and use of CCUS. Ultrasound competency on multiple organ systems was assessed including abdominal, pulmonary, vascular, and cardiac systems. Subjects served as self-controls and were assessed just prior to, within 1 week after, and 3 months after the course. Results. There was a significant improvement in CCM fellows' written test scores, image acquisition ability, and pathologic image interpretation 1 week after the course and it was retained 3 months after the course. Fellows also had self-reported increased confidence and usage of CCUS applications after the course. Conclusions. Implementation of a 2-day critical care ultrasound course covering general CCUS and basic critical care echocardiography using a combination of didactics, live models, and ultrasound simulators is effective in improving critical care fellows' proficiency and confidence with ultrasound use in both the short- and long-term settings.
Critical care research and practice 09/2015; 2015:675041. DOI:10.1155/2015/675041
[Show abstract][Hide abstract] ABSTRACT: Recent studies have reported decreased overall severe sepsis mortality, but associations with organism trends have not yet been investigated. This study explored organism-specific severe sepsis mortality trends from 1999 to 2008 in a large hospital-based administrative database.
Critical Care Medicine 09/2014; 43(1). DOI:10.1097/CCM.0000000000000555 · 6.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Severe sepsis patients with initial lactate level 2–4 mM are commonly considered to have lower risk for mortality and adverse outcomes.
Aim: We aim to determine clinical variables that are associated with adverse outcome in these patients.
Design: A retrospective cohort study.
Methods: Severe sepsis patients with initial lactate ≥2 and <4 mM admitted to our hospital were examined for any of the following primary outcomes: (i) in-hospital death, (ii) vasopressor requirement, (iii) use of mechanical ventilator, (iv) lactate ≥4.0 mM or (v) need care in the intensive care unit (ICU) within 48 h.
Results: Five-hundred and thirty-five patients were enrolled, age 58.7 ± 19.3 years, 53.2% male. The most common sources of infection were urinary tract infection and pneumonia, 38.3 and 35.7%, respectively. One-hundred and twenty-four (23.2%) patients had at least one primary adverse outcome within 48 h, including in-hospital death 1.1%, vasopressor requirement 12.9%, use of mechanical ventilator 13.3%, increase lactate ≥4.0 mM in 5.6% patients and 21.5% of patients requiring ICU (including 13.8% of the patients admitted directly to ICU from the emergency department, and 7.7% initially admitted to the general medical ward but later required ICU transfer). Altered mentation, hypotension, tachypnea and elevated blood urea nitrogen at admission were associated with the primary outcome in multivariable logistic regression analysis, odds ratio 2.50 (95% confidence interval: 1.54, 4.06), 3.76 (2.31, 6.10), 1.97 (1.22, 3.17) and 1.78 (1.11, 2.83), respectively.
Conclusions: Our study suggests that clinicians should be cautious about the potential adverse outcomes in severe sepsis patients with initial lactate level between 2 and 4 mM and a presentation of altered mentation, hypotension, tachypnea and/or elevated blood urea nitrogen.
QJM: monthly journal of the Association of Physicians 09/2014; 108(4). DOI:10.1093/qjmed/hcu186 · 2.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
The purpose of our study was to compare the agreement of emergency physician diagnoses relative to the 1991 American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM) and 2001 ACCP/SCCM/European Society of Intensive Care Medicine/American Thoracic Society/Surgical Infection Society internationally accepted definitions of sepsis, severe sepsis, and septic shock.
Materials and methods:
This study was an observational cohort study of adult patients presenting to the emergency department (ED) with a chief complaint suggestive of infection over a 6-week period, during a daily enrollment schedule from 7:00 am to 10:00 pm. Patients were categorized as having "no sepsis," "sepsis," "severe sepsis," or "septic shock" based on ED physician diagnosis, the 1991 definitions, or 2001 definitions. Agreement statistics were performed.
A total of 1275 patients were enrolled with age 50.1 ± 21.7 years and 59.1% were female. Among the enrolled patients, 228 were identified as having a source of infection. Temperature, heart rate, and white blood cell count were significantly higher in patients with infection, compared with those without (P < .001). The odds ratio for disagreement between a physician-designated no sepsis diagnosis and the 1991 definitions was 4.47 (95% confidence interval, 3.01-7.53) and 5.96 (3.78-9.46) between the same physician-designated diagnosis and the 2001 definitions. The odds ratios for disagreement of a severe sepsis physician diagnosis in relation to the 1991 and 2001 definitions were 0.06 (0.01-0.19) and 0.06 (0.01-0.20), respectively. The 1991 and 2001 consensus definitions had strong agreement, with κ = 0.86 and 91.2% agreement. No agreement was found between the physician diagnosis and 1991 consensus sepsis definitions (κ = 0.11 and 52.2% agreement) or between the physician diagnosis and the 2001 consensus sepsis definitions (κ = 0.13 and 50.0% agreement).
Our study showed that ED physician diagnosis of sepsis may disagree with the international definitions such that severe sepsis is underrecognized by clinical judgment alone. Although these results are limited to a single center, we raise concern that early treatments for these high-risk patients may be delayed due to inaccurate clinical diagnosis. Efforts are needed to increase the application of sepsis guideline definitions to better identify ED patients with this potentially deadly condition.
Journal of Critical Care 08/2014; 30(1). DOI:10.1016/j.jcrc.2014.08.009 · 2.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives:
Sonographic evaluation of neck anatomy before performing percutaneous dilatational tracheostomy (PDT) has been shown to predict PDT success. In this study, we compared the real-time, long-axis, in-plane approach to the traditional bronchoscopically guided landmark technique.
Data were analyzed from a prospectively maintained PDT database at a university tertiary care medical intensive care unit. A convenience sample of adult patients requiring PDT for prolonged mechanical ventilation dependence was enrolled. Critical care fellows, under direct supervision of an attending intensivist, performed all PDTs. Tracheostomy performance from the sonographically guided and landmark techniques was compared.
Twenty-three patients were enrolled: 11 in the sonography group and 12 in the landmark group. Initial midline introducer needle puncture was achieved in 72.7% in the sonography group compared to 8.3% in the landmark group (P< .001). The mean number of introducer needle punctures ± SD was significantly lower in the sonography group compared to the landmark group (1.4 ± 0.7 versus 2.6 ± 0.9; P < .001). The total tracheostomy time was 11.4 ± 4.2 minutes in the sonography group versus 15.3 ± 6.8 minutes in the landmark group (P = .12). Sonography accurately predicted tracheal ring space insertion in 90.9% of patients. Procedural complications did not differ significantly between the groups.
Percutaneous dilatational tracheostomy under real-time sonographic guidance using a long-axis approach may increase the rate of midline punctures and decrease the number of needle punctures when compared to the landmark technique. Sonographic guidance can also help guide accurate and efficient placement of a tracheostomy tube into the desired tracheal ring space.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 08/2014; 33(8):1407-15. DOI:10.7863/ultra.33.8.1407 · 1.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The authors aimed to evaluate age-related differences in inflammation biomarkers during the first 72 h of hospitalization for sepsis. This was a secondary analysis of a prospective observational cohort of adult patients (n = 855) from 10 urban academic emergency departments with confirmed infection and two or more systemic inflammatory response syndrome criteria. Six inflammation-related biomarkers were analyzed-chemokine (CC-motif) ligand-23, C-reactive protein, interleukin-1 receptor antagonist, neutrophil gelatinase-associated lipocalin (NGAL), peptidoglycan recognition protein, and tumor necrosis factor receptor-1a (TNFR-1a)-measured at presentation and 3, 6, 12, 24, 48, or 72 h later. The median age was 56 (interquartile range, 43 - 72) years, and sepsis severity was 38% sepsis, 16% severe sepsis without shock, and 46% septic shock; the overall 30-day mortality was 12%. Older age was associated with higher sepsis severity: 41% of subjects aged 18 to 34 years had severe sepsis or septic shock compared with 71% for those aged 65 years or older (P < 0.001). In longitudinal models adjusting for demographics, comorbidities, and infection source, older age was associated with higher baseline values for chemokine (CC-motif) ligand-23, interleukin-1 receptor antagonist, NGAL, and TNFR-1a (all P < 0.05). However, older adults had higher mean values during the entire 72-h period only for NGAL and TNFR-1a and higher final 72-h values only for TNFR-1a. Adjustment or stratification by sepsis severity did not change the age-inflammation associations. Although older adults had higher levels of inflammation at presentation and an increased incidence of severe sepsis and septic shock, these age-related differences in inflammation largely resolved during the first 72 h of hospitalization.
[Show abstract][Hide abstract] ABSTRACT: Rationale. We recently reported two novel biomarkers for acute kidney injury (AKI), tissue inhibitor of metalloproteinases (TIMP)-2 and insulin-like growth factor binding protein 7 (IGFBP7), both related to G1 cell cycle arrest. Objectives. We now validate a clinical test for urinary [TIMP-2]•[IGFBP7] at a high-sensitivity cutoff > 0.3 for AKI risk stratification in a diverse population of critically ill patients. Methods. We conducted a prospective multicenter study of 420 critically ill patients. The primary analysis was the ability of urinary [TIMP-2]•[IGFBP7] to predict moderate to severe AKI within 12 hours. AKI was adjudicated by a committee of three independent expert nephrologists who were blinded to the results of the test. Measurements. Urinary TIMP-2 and IGFBP7 were measured using a clinical immunoassay platform. Main Results. The primary endpoint was reached in 17% of patients. For a single urinary [TIMP-2]•[IGFBP7] test, sensitivity at the pre-specified high-sensitivity cutoff of 0.3 (ng/ml)2/1000 was 92% (95% CI 85%-98%) with a negative likelihood ratio of 0.18 (95% CI 0.06-0.33). Critically ill patients with urinary [TIMP-2]•[IGFBP7] > 0.3 had seven times the risk for AKI (95% CI 4-22) compared to critically ill patients with a test result below 0.3. In a multivariate model including clinical information, urinary [TIMP-2]•[IGFBP7] remained statistically significant and a strong predictor of AKI (AUC 0.70, 95% CI 0.63-0.76 for clinical variables alone, versus AUC 0.86, 95% CI 0.80-0.90 for clinical variables plus [TIMP-2]•[IGFBP7]). Conclusions. Urinary [TIMP-2]•[IGFBP7] > 0.3 (ng/ml)2/1000 identifies patients at risk for imminent AKI. Funding. Funded by Astute Medical. (ClinicalTrials.gov NCT01573962).
American Journal of Respiratory and Critical Care Medicine 02/2014; 189(8). DOI:10.1164/rccm.201401-0077OC · 13.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In sepsis, the vitamin D active metabolite 1,25-dihydroxyvitamin D (1,25(OH)2D) may play a crucial role by its action to produce cathelicidin and improve endothelial barrier function, such that a deficiency in 1,25(OH)2D is associated with poor outcome. To test our hypothesis, we performed analysis of stored plasma samples from a prospective observational study in 91 patients with sepsis, age of 59.1+/-2.0 years, 52.7% females, and 11.0% deaths at 30 days. Vitamin D status, including 25-hydroxyvitamin D (25(OH)D), 1,25(OH)2D, 24,25-dihydroxyvitamin D (24,25(OH)2D), and parathyroid hormone (PTH), were measured daily over 3 days after hospital admission. At baseline, 1,25(OH)2D was significantly different between survivors vs. non-survivors. But there was no significant difference in 25(OH)D, 24,25(OH)2D, and PTH. In a multivariable binomial logistic regression model, age, total calcium and 1,25(OH)2D were significant predictors of 30-day mortality. Kaplan Meier analysis showed that patients with mean 1,25(OH)2D measured over 3 days of < = 13.6 pg/mL had 57.1% 30-day survival compared to 91.7% in patients with 1,25 (OH)2D level >13.6 pg/mL (p<0.01). From repeated measures regression analysis, there was significant increase in 1,25(OH)2D for increases in 25(OH)D in both survivors and non-survivors. However, compared to survivors, the low 25(OH)D in non-survivors was insufficient to account for the larger decrease in 1,25(OH)2D, indicating a dysfunctional 1α-hydroxylase. Additionally, there was a significant negative correlation between PTH and 1,25(OH)2D in both survivors and non-survivors, suggesting a severe impairment in the effect of PTH to increase renal 1α-hydroxylase activity. In conclusion, low 1,25(OH)2D levels are associated with increased 30-day mortality in sepsis patients, likely due to impaired 25(OH)D hydroxylation and PTH insensitivity. Our data also suggest that the active metabolite 1,25(OH)2D may be an important therapeutic target in the design of sepsis clinical trials.
PLoS ONE 05/2013; 8(5):e64348. DOI:10.1371/journal.pone.0064348 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Improving time to diagnosis and intervention has positively impacted outcomes in acute myocardial infarction, stroke, and trauma through elucidating the early pathogenesis of those diseases. This insight may partly explain the futility of time-insensitive immunotherapy trials for severe sepsis and septic shock. The aim of this study was to examine the early natural history of circulatory biomarker activity in sepsis, relative to previous animal and human outcome trials. We conducted a literature search using PubMed, MEDLINE, and Google Scholar to identify outcome trials targeting biomarkers with emphasis on the timing of therapy. These findings were compared with the biomarker activity observed over the first 72 h of hospital presentation in a cohort of severe sepsis and septic shock patients. Biomarker levels in animal and human research models are elevated within 30 min after exposure to an inflammatory septic stimulus. Consistent with these findings, the biomarker cascade is activated at the most proximal point of hospital presentation in our patient cohort. These circulatory biomarkers overlap; some have bimodal patterns and generally peak between 3 and 36 h while diminishing over the subsequent 72 h of observation. When this is taken into account, prior outcome immunotherapy trials have generally enrolled patients after peak circulatory biomarker concentrations. In previous immunotherapy sepsis trials, intervention was delayed after the optimal window of peak biomarker activity. As a result, future studies need to recalibrate the timing of enrollment and administration of immunotherapy agents that still may hold great promise for this deadly disease.
[Show abstract][Hide abstract] ABSTRACT: : The primary objective of this study was to identify which patient demographic, patient health, and hospital characteristics were associated with in-hospital mortality. A secondary objective was to determine the relative influence of these characteristics on mortality.
: Public-use data for 2005-2010 were used in this retrospective, cross-sectional analysis of discharges from nonfederal, general acute hospitals in California. A staged logistic regression approach was used to examine the relative influence of variables associated with in-hospital mortality.
: A total of 1,213,219 patient discharges for adults (aged ≥18 yrs) having International Classification of Diseases-9 diagnosis and procedure codes indicating severe sepsis.
: Patient demographics (age, gender, race, ethnicity, and payer category), patient health status (acute transfer, Charlson-Deyo comorbidity index, and organ failures), and hospital characteristics (ownership type, teaching status, bed size, annual patient days, acute discharges, emergency department visits, inpatient surgeries, severe sepsis as a percentage of all discharges, and year) were obtained from the California Office of Statewide Health Planning and Development. Overall, in-hospital mortality was 17.8%. There was a steady annual increase in the number of sepsis discharges, but a decrease in mortality throughout the study period. Mortality increased with age and was associated with white race, and Medicaid (Medi-Cal) and private insurance. Patient health status additionally explained inpatient mortality. Hospital volume measures were statistically significant in regression analysis, whereas static structural measures were not. There were modest associations between measures of annual treatment volume and likelihood of inpatient mortality, notably decreasing likelihood with more acute discharges and with greater severe sepsis volume.
: Although patient demographics and health status are the most important predictors of in-hospital mortality of patients with severe sepsis, hospital characteristics do play a substantial role. Findings regarding hospital volume can be used to improve processes and improve patient outcomes.
Critical care medicine 08/2012; 40(11):2960-6. DOI:10.1097/CCM.0b013e31825bc92f · 6.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To examine the impact of implementing sepsis bundle in multiple Asian countries, having 'team' vs. 'non-team' models of patient care. DESIGN: /st> Prospective cohort study. SETTING: /st> Eight urban hospitals, five countries in Asia. PARTICIPANTS: /st> Adult patients with severe sepsis or septic shock. INTERVENTIONS: /st> Implementation was divided into six quartiles: Baseline, Education and four Quality Improvement quartiles. MAIN OUTCOME MEASURES: /st> Quarterly bundle compliance and in-hospital mortality with respect to bundle completion and implementation model. METHODS: /st> In the team model, the implementation was championed by intensivists, where the bundle was completed in the intensive care unit. The non-team model led by emergency physicians completed the bundle in the emergency department as part of standard care. RESULTS: /st> Five hundred and fifty-six patients were enrolled. The overall in-hospital mortality rate was 29.9%, and 67.1% of the patients had septic shock. Compliance to the bundle was 13.3, 26.9, 37.5, 45.9, 48.8 and 54.5% over the six quartiles of implementation (P < 0.01). With team model, compliance increased from 37.5% baseline to 88.2% in the sixth quartile (P < 0.01), whereas hospitals with a non-team model increased compliance from 5.2 to 39.5% (P < 0.01). Crude in-hospital mortality was better in the patients who received the entire bundle (24.5 vs. 32.7%, P = 0.04). Bundle completion was associated with crude in-hospital mortality reduction (odds ratio 0.67, 95% confidence interval 0.45-0.99), but this survival benefit disappeared after adjustment for confounding variables. CONCLUSIONS: /st> Through education and quality improvement efforts, initially low sepsis bundle compliance was improved in Asia. A team model was more effective in achieving bundle compliance compared with a non-team model.
International Journal for Quality in Health Care 08/2012; 24(5):452-462. DOI:10.1093/intqhc/mzs045 · 1.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives:
Noninvasive technology may assist the emergency department (ED) physician in determining the hemodynamic status in critically ill patients. The objective of our study was to show that ED physicians can accurately measure cardiac index (CI) by performing a bedside focused cardiac ultrasound examination.
A convenience sample of adult subjects were prospectively enrolled. Cardiac index, left ventricular outflow tract (LVOT) diameter, velocity time integral (VTI), stroke volume index, and heart rate were obtained by trained ED physicians and a certified cardiac sonographer. The primary outcome was percent of optimal LVOT diameter and VTI measurements as verified by an expert cardiologist.
One hundred patients were enrolled, with obtainable CI measurements in 97 patients. Cardiac index, LVOT diameter, VTI, stroke volume index, and heart rate measurements by ED physician were 2.42 ± 0.70 L min(-1) m(-2), 2.07 ± 0.22 cm, 18.30 ± 3.71 cm, 32.34 ± 7.92 mL beat(-1) m(-2), and 75.32 ± 13.45 beats/min, respectively. Measurements of LVOT diameter by ED physicians and sonographer were optimal in 90.0% (95% confidence interval, 82.6%-94.5) and 91.3% (73.2%-97.6%) of patients, respectively. Optimal VTI measurements were obtained in 78.4% (69.2%-85.4%) and 78.3% (58.1%-90.3%) of patients, respectively. In 23 patients, the correlation (r) for CI between ED physician and sonographer was 0.82 (0.60-0.92), with bias and limits of agreement of -0.11 (-1.06 to 0.83) L min(-1) m(-2) and percent difference of 12.4% ± 10.1%.
Emergency department ED physicians can accurately measure CI using standard bedside ultrasound. A focused ultrasound cardiac examination to derive CI has potential use in the management of critical ill patients in the ED.
The American journal of emergency medicine 07/2012; 30(9). DOI:10.1016/j.ajem.2012.03.025 · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Lactic acid was first discovered in human blood in 1843. Since then it has been used as a prognosticator of outcome in critical illness. Regardless of its etiology, lactate's presence and trend over time have been shown to be independently associated with mortality. Two dynamic lactate measures, the time-weighted average lactate and the absolute change in lactate over the first 24 hours in the ICU, were recently shown to be better than static lactate measurements in predicting hospital and ICU deaths.
[Show abstract][Hide abstract] ABSTRACT: Spontaneous aortic dissection in pregnancy is rare and life threatening for both the mother and the fetus. Most commonly, it is associated with connective tissue disorders, cardiac valve variants, or trauma. We present the case of a 23-year-old previously healthy woman, 36 weeks pregnant with a syncopal episode after dyspnea and vomiting. She subsequently developed cardiac arrest and underwent aggressive resuscitation, emergent thoracotomy, and cesarean delivery without recovery. On autopsy, she was found to have an aortic dissection of the ascending aorta. This case is presented to raise awareness and review the literature and the clinical approach to critical care for pregnant patients.
The western journal of emergency medicine 11/2011; 12(4):571-4. DOI:10.5811/westjem.2011.5.2257
[Show abstract][Hide abstract] ABSTRACT: The aim of the study was to examine the performance of the Predisposition, Insult/Infection, Response, and Organ dysfunction (PIRO) model compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Mortality in Emergency Department Sepsis (MEDS) scoring systems in predicting in-hospital mortality for patients presenting to the emergency department (ED) with severe sepsis or septic shock.
This study was an analysis of a prospectively maintained registry including adult patients with severe sepsis or septic shock meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle over a 6-year period. The registry contains data on patient demographics, sepsis category, vital signs, laboratory values, ED length of stay, hospital length of stay, physiologic scores, and outcome status. The discrimination and calibration characteristics of PIRO, APACHE II, and MEDS were analyzed.
Five-hundred forty-one patients with age 63.5 ± 18.5 years were enrolled, 61.9% in septic shock, 46.9% blood-culture positive, and 31.8% in-hospital mortality. Median (25th and 75th percentile) PIRO, APACHE II, and MEDS scores were 6 (5 and 8), 28 (22 and 34), and 12 (9 and 15), with predicted mortalities of 48.5% (40.1 and 63.9), 66.0% (42.0 and 83.0), and 16.0% (9.0 and 39.0), respectively. The area under the receiver operating characteristic curves for PIRO was 0.71 (95% confidence interval, 0.66-0.75); APACHE II, 0.71 (0.66-0.76); and MEDS, 0.63 (0.60-0.70). The standardized mortality ratio was 0.70 (0.08-1.41), 0.70 (-0.46 to 1.80), and 4.00 (-8.53 to 16.62), respectively. Actual mortality significantly increased with increasing PIRO score in patients with APACHE II 25 or more (P < .01).
The PIRO, APACHE II, and MEDS have variable abilities to early discriminate and estimate in-hospital mortality of patients presenting to the ED meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The PIRO may provide additional risk stratification in patients with APACHE II 25 or more. More studies are required to evaluate the clinical applicability of PIRO in high-risk patients with severe sepsis and septic shock.
Journal of critical care 10/2011; 27(4):362-9. DOI:10.1016/j.jcrc.2011.08.013 · 2.00 Impact Factor