L D Hudson

University of Toronto, Toronto, Ontario, Canada

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Publications (125)1334.42 Total impact

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    ABSTRACT: OBJECTIVE:: To determine whether benzodiazepine and propofol doses are increased at night and whether daytime and nighttime sedative doses are associated with delirium, coma, and delayed liberation from mechanical ventilation. DESIGN:: Single-center, prospective cohort study nested within the Awakening and Breathing Controlled randomized trial. SETTING:: Saint Thomas Hospital in Nashville, TN, from 2004 to 2006. PATIENTS:: Adult patients receiving mechanical ventilation for >12 hrs with continuous recording of hourly sedation dosing. INTERVENTIONS:: We measured hourly doses of benzodiazepine and propofol exposure during the daytime (7 AM to 11 PM) and nighttime (11 PM to 7 AM) for 5 days. We quantified nighttime dose increases by subtracting the average hourly daytime dose on the preceding day from subsequent average hourly nighttime dose. We used multivariable logistic regression to determine whether daytime and nighttime dose increases were independently associated with delirium, coma, and delayed liberation from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS:: Among 140 patients, the median Acute Physiology and Chronic Health Evaluation II score was 27 (interquartile range 22-33). Among those receiving the sedatives, benzodiazepine and propofol doses were increased at night on 40% and 41% of patient-days, respectively. Of 485 patient-days, delirium was present on 160 (33%) and coma on 206 (42%). In adjusted models, greater daytime benzodiazepine dose was independently associated with failed spontaneous breathing trial and extubation, and subsequent delirium (p < .02 for all). Nighttime increase in benzodiazepine dose was associated with failed spontaneous breathing trial (p < .01) and delirium (p = .05). Daytime propofol dose was marginally associated with subsequent delirium (p = .06). CONCLUSIONS:: Nearly half of mechanically ventilated intensive care unit patients received greater doses of sedation at night, a practice associated with failed spontaneous breathing trials, coma, and delirium. Over the first 5 days in our study, patients spent 75% of their time in coma or delirium, outcomes that may be reduced by efforts to decrease sedative exposure during both daytime and nighttime hours in the intensive care unit.
    Critical care medicine 07/2012; 40(10):2788-2796. DOI:10.1097/CCM.0b013e31825b8ade · 6.15 Impact Factor
  • American Thoracic Society 2011 International Conference, May 13-18, 2011 • Denver Colorado; 05/2011
  • American Thoracic Society 2010 International Conference, May 14-19, 2010 • New Orleans; 05/2010
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    ABSTRACT: Little is known about the participation of racial/ethnic minorities, women, and the elderly into critical care clinical trials. We sought to characterize the representation of racial and ethnic minorities, women, and older patients in clinical trials of patients with acute lung injury and to determine the reasons for nonenrollment. We performed a cross-sectional analysis of pooled screening logs from 44 academic hospitals participating in three multicentered, randomized, controlled trials conducted by the Acute Respiratory Distress Syndrome Network from 1996 to 2005. None. We calculated odds ratios of enrollment for age, sex, racial groups, and the odds ratio for the presence of each exclusion criterion by age, sex, and race adjusted for demographics, acute lung injury risk factor, study, and study center. A total of 10.4% of 17,459 screened patients with acute lung injury were enrolled. The median (range) enrollment by center was 15% (2% to 88%). Older patients of both sexes were less likely to be enrolled, but older women were more likely to be enrolled than older men. The adjusted odds ratio (95% confidence interval) for enrollment among men > or =75 yrs of age was 0.59 (0.45 to 0.77) and for women > or =75 yrs of age was 0.45 (0.32 to 0.62) compared with men <35 yrs of age. There were no differences in the likelihood of enrollment among all racial/ethnic groups. Older patients and men were less likely to be enrolled because of medical comorbidity. Among all patients who were not enrolled, black patients and their families refused participation more often than white patients. Older patients are less likely to be enrolled in acute lung injury clinical trials. There is no evidence that women or racial/ethnic minorities are underrepresented in acute lung injury clinical trials.
    Critical care medicine 04/2010; 38(6):1450-7. DOI:10.1097/CCM.0b013e3181de451b · 6.15 Impact Factor
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    ABSTRACT: : To investigate if light sedation favorably affects subsequent patient mental health compared with deep sedation. Symptoms of posttraumatic stress disorder are common in patients after they have undergone prolonged mechanical ventilation and are associated with sedation depth. : Randomized, open-label, controlled trial. : Single tertiary care center. : Adult patients requiring mechanical ventilation. : Patients were randomized to receive either light (patient awake and cooperative) or deep sedation (patient asleep, awakening upon physical stimulation). : Self-reported measures of posttraumatic stress disorder, anxiety, and depression were collected at intensive care unit discharge and 4 wks later. The primary outcomes were symptoms of posttraumatic stress disorder, anxiety, and depression 4 wks after intensive care unit discharge.A total of 137 patients were assigned to either the light (n = 69) or the deep sedation (n = 68) group. Seven patients withdrew consent and one patient was randomized in error, leaving 129 patients (n = 65 in light sedation and n = 64 in deep sedation) available for analysis. At the 4-wk follow-up, patients in the deep sedation group tended to have more posttraumatic stress disorder symptoms (p = .07); the deep sedation group had more trouble remembering the event (37% vs. 14%; p = .02) and more disturbing memories of the intensive care unit (18% vs. 4%; p = .05). Patients in the light sedation group had an average one day less being ventilated and 1.5 fewer days in the intensive care unit. There were no differences between the two groups in the occurrence of anxiety and depression, and also no difference in mortality or in the incidence of adverse events. : These data suggest that a strategy of light sedation affords benefits with regard to reduction of intensive care unit stay and duration of ventilation without negatively affecting subsequent patient mental health or patient safety.
    Critical care medicine 08/2009; 37(9):2527-34. DOI:10.1097/CCM.0b013e3181a5689f · 6.15 Impact Factor
  • Patricia A Kritek, Arthur S Slutsky, Leonard D Hudson
    New England Journal of Medicine 04/2009; 360(10):e15. DOI:10.1056/NEJMclde0900810 · 54.42 Impact Factor
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    ABSTRACT: Despite widespread guidelines recommending the use of lung-protective ventilation (LPV) in patients with acute lung injury (ALI), many patients do not receive this lifesaving therapy. We sought to estimate the incremental clinical and economic outcomes associated with LPV and determined the maximum cost of a hypothetical intervention to improve adherence with LPV that remained cost-effective. Adopting a societal perspective, we developed a theoretical decision model to determine the cost-effectiveness of LPV compared to non-LPV care. Model inputs were derived from the literature and a large population-based cohort of patients with ALI. Cost-effectiveness was determined as the cost per life saved and the cost per quality-adjusted life-years (QALYs) gained. Application of LPV resulted in an increase in QALYs gained by 15% (4.21 years for non-LPV vs 4.83 years for LPV), and an increase in lifetime costs of $7,233 per patient with ALI ($99,588 for non-LPV vs $106,821 for LPV). The incremental cost-effectiveness ratios for LPV were $22,566 per life saved at hospital discharge and $11,690 per QALY gained. The maximum, cost-effective, per patient investment in a hypothetical program to improve LPV adherence from 50 to 90% was $9,482. Results were robust to a wide range of economic and patient parameter assumptions. Even a costly intervention to improve adherence with low-tidal volume ventilation in patients with ALI reduces death and is cost-effective by current societal standards.
    Chest 04/2009; 136(1):79-88. DOI:10.1378/chest.08-2123 · 7.13 Impact Factor
  • Arthur S Slutsky, Leonard D Hudson
    New England Journal of Medicine 02/2009; 360(5):527-31. DOI:10.1056/NEJMclde0808330 · 54.42 Impact Factor
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    ABSTRACT: The translation of basic research advances to the clinical arena has been slow and inefficient. With the goal of improving interactions and collaboration between basic science and clinical investigators, we instituted a Translational Research Training Program (TRTP) in acute lung injury to complement our basic science and clinical research training programs in pulmonary and critical care medicine. We developed a TRTP in which trainees select a primary research discipline for rigorous development of skills in either basic science research or clinical research. This primary foundation is complemented by cross-training in the other discipline through a specifically designed program of study. To measure the impact of the program, we analyzed publication rates, coauthorship to reflect collaboration between research disciplines, and publication of papers with a translational focus by members of our division before and after the institution of the TRTP. We describe our new training program, including modifications to our preexisting program and development of new components. We found significant increases in multidisciplinary authorship and translational articles following institution of TRTP. An explicit TRTP appears to increase collaboration between basic and clinical investigators. Our goal is to share our experiences and provide a template for other pulmonary and critical care programs interested in developing similar curricula. We speculate that this training will improve the translation of basic research findings into clinical advances, thus increasing the probability that successful treatments will be developed for patients with lung diseases.
    Chest 12/2008; 135(3):688-94. DOI:10.1378/chest.08-1449 · 7.13 Impact Factor
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    ABSTRACT: To determine the incidence and outcomes of intensive care unit-acquired neuromyopathy and to investigate the role of methylprednisolone in survivors of persistent acute lung injury. Secondary analysis of completed randomized placebo-controlled trial. Twenty-five hospitals in the NHLBI ARDS Network. Patients enrolled in the ARDS Network study of methylprednisolone versus placebo for persistent ARDS who survived 60 days or to hospital discharge. One hundred and twenty-eight study patients survived 60 days. Forty-three (34%) of these patients had evidence by chart review of ICU-acquired neuromyopathy, which was associated with prolonged mechanical ventilation, return to mechanical ventilation, and delayed return to home after critical illness. Treatment with methylprednisolone was not significantly associated with an increase in risk of neuromyopathy (OR 1.5; 95% CI 0.7-3.2). ICU-acquired-neuromyopathy is common among survivors of persistent ARDS and is associated with poorer clinical outcomes. We did not find a significant association between methylprednisolone treatment and neuromyopathy. Limitations of this study preclude definitive conclusions about the causal relationship between corticosteroids and ICU-acquired neuromuscular dysfunction.
    European Journal of Intensive Care Medicine 11/2008; 35(1):63-8. DOI:10.1007/s00134-008-1304-4 · 5.17 Impact Factor
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    ABSTRACT: Introduction Little is known about the mechanisms through which intensivist physician staffing influences patient outcomes. We aimed to assess the effect of closed-model intensive care on evidence-based ventilatory practice in patients with acute lung injury (ALI). Methods We conducted a secondary analysis of a prospective population-based cohort of 759 patients with ALI who were alive and ventilated on day three of ALI, and were cared for in 23 intensive care units (ICUs) in King County, Washington. Results We compared day three tidal volume (VT) in open versus closed ICUs adjusting for potential patient and ICU confounders. In 13 closed model ICUs, 429 (63%) patients were cared for. Adjusted mean VT (mL/Kg predicted body weight (PBW) or measured body weight if height not recorded) for patients in closed ICUs was 1.40 mL/Kg PBW (95% confidence interval (CI) = 0.57 to 2.24 mL/Kg PBW) lower than patients in open model ICUs. Patients in closed ICUs were more likely (odds ratio (OR) = 2.23, 95% CI = 1.09 to 4.56) to receive lower VT (≤ 6.5 mL/Kg PBW) and were less likely (OR = 0.30, 95% CI = 0.17 to 0.55) to receive a potentially injurious VT (≥ 12 mL/Kg PBW) compared with patients cared for in open ICUs, independent of other covariates. The effect of closed ICUs on hospital mortality was not changed after accounting for delivered VT. Conclusions Patients with ALI cared for in closed model ICUs are more likely to receive lower VT and less likely to receive higher VT, but there were no other differences in measured processes of care. Moreover, the difference in delivered VT did not completely account for the improved mortality observed in closed model ICUs.
    Critical care (London, England) 11/2008; 12(6). DOI:10.1186/cc7105 · 5.04 Impact Factor
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    ABSTRACT: Studies describing predictors of mortality in patients with acute lung injury were primarily derived from selected academic centers. We sought to determine the predictors of mortality in a population-based cohort of patients with acute lung injury and to characterize the performance of current severity of illness scores in this population. Secondary analysis of a prospective, multicenter, population-based cohort. Twenty-one hospitals in Washington State. The cohort included 1,113 patients with acute lung injury identified during the year 1999-2000. None. We evaluated physiology, comorbidities, risk factors for acute lung injury, and other variables for their association with death at hospital discharge. Bivariate predictors of death were entered into a multiple logistic regression model. We compared Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, and Simplified Acute Physiology Score II to the multivariable model using area under the receiver operating characteristic curve. The model was validated in an independent cohort of 886 patients with acute lung injury. Modified acute physiology score, age, comorbidities, arterial pH, minute ventilation, PaCO2, PaO2/FiO2 ratio, intensive care unit admission source, and intensive care unit days before onset of acute lung injury were independently predictive of in-hospital death (p < .05). The area under the receiver operating characteristic curve for the multivariable model was superior to that of APACHE III (.81 vs. .77, p < .001) but was no different after external validation (.71 vs. .70, p = .64). The predictors of mortality in patients with acute lung injury are similar to those predictive of mortality in the general intensive care unit population, indicating disease heterogeneity within this cohort. Accordingly, APACHE III predicts mortality in acute lung injury as well as a model using variables selected specifically for patients with acute lung injury.
    Critical care medicine 05/2008; 36(5):1412-20. DOI:10.1097/CCM.0b013e318170a375 · 6.15 Impact Factor
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    ABSTRACT: Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients. To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA). Cohort study of patients with acute lung injury (ALI). ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition. Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.
    American Journal of Respiratory and Critical Care Medicine 11/2007; 176(7):685-90. DOI:10.1164/rccm.200701-165OC · 11.99 Impact Factor
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    ABSTRACT: The association between body mass index (BMI) and outcomes in critically ill patients is unclear. Our objective was to determine the association between BMI and outcomes in a population-based cohort of patients with acute lung injury (ALI). In a prospective cohort study of all ICU patients in King County, Washington, with ALI in 1 year (1999 to 2000), 825 patients had a BMI recorded. Using multivariate analysis, patients in the abnormal BMI groups were compared to normal patients in the following areas: mortality, hospital length of stay (LOS), ICU LOS, duration of mechanical ventilation, and discharge disposition. There was no mortality difference in any of the abnormal BMI groups compared to normal-weight patients. Severely obese patients had longer hospital LOS than normal-weight patients (mean increase, 10.5 days; 95% confidence interval [CI], 4.8 to 16.2 days; p < 0.001); this was accentuated when analysis was restricted to survivors (mean increase, 14.3 days; 95% CI, 7.1 to 21.6 days; p < 0.001). ICU LOS and duration of mechanical ventilation were also longer in the severely obese group when analysis was restricted to survivors (mean increase, 5.6 days; 95% CI, 1.3 to 9.8 days; p = 0.01; and mean increase, 4.1 days; 95% CI, 0.4 to 7.7 days, respectively; p = 0.03). Severely obese patients were more likely to be discharged to a rehabilitation or skilled nursing facility than to home. BMI is not associated with mortality in patients with ALI, but severe obesity is associated with increased morbidity and resource utilization in the hospital and after discharge.
    Chest 03/2007; 131(2):342-8. DOI:10.1378/chest.06-1709 · 7.13 Impact Factor
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    Critical care (London, England) 02/2007; 11(6):425. DOI:10.1186/cc6186 · 5.04 Impact Factor
  • Leonard D Hudson, Catherine Lee Hough
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    ABSTRACT: Prolonged hypoxemic respiratory failure and evidence of lung organization and fibrosis are features of an ARDS subgroup that is variably identified as "late," "persistent," or "fibroproliferative" ARDS. Early reports suggested that patients with late ARDS had a high mortality unless treated with corticosteroids. A large recent study with improved methodology has demonstrated that despite improvements of pulmonary physiology, corticosteroids do not change mortality of patients who continue to meet ARDS criteria 7 to 28 days after onset of acute lung injury. Additionally, there is no compelling evidence that persistent ARDS confers a higher mortality than that of ALI/ARDS. Observational and interventional studies are needed to increase understanding of the incidence, best management, and outcomes of patients with persistent ARDS.
    Clinics in Chest Medicine 01/2007; 27(4):671-7; abstract ix-x. DOI:10.1016/j.ccm.2006.08.001 · 2.17 Impact Factor
  • LINDA ROSENSTOCK, LEONARD D. HUDSON
    Annals of the New York Academy of Sciences 12/2006; 643(1):296 - 300. DOI:10.1111/j.1749-6632.1991.tb24475.x · 4.38 Impact Factor
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    Arthur S Slutsky, Leonard D Hudson
    New England Journal of Medicine 05/2006; 354(17):1839-41. DOI:10.1056/NEJMe068045 · 54.42 Impact Factor
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    ABSTRACT: Persistent acute respiratory distress syndrome (ARDS) is characterized by excessive fibroproliferation, ongoing inflammation, prolonged mechanical ventilation, and a substantial risk of death. Because previous reports suggested that corticosteroids may improve survival, we performed a multicenter, randomized controlled trial of corticosteroids in patients with persistent ARDS. We randomly assigned 180 patients with ARDS of at least seven days' duration to receive either methylprednisolone or placebo in a double-blind fashion. The primary end point was mortality at 60 days. Secondary end points included the number of ventilator-free days and organ-failure-free days, biochemical markers of inflammation and fibroproliferation, and infectious complications. At 60 days, the hospital mortality rate was 28.6 percent in the placebo group (95 percent confidence interval, 20.3 to 38.6 percent) and 29.2 percent in the methylprednisolone group (95 percent confidence interval, 20.8 to 39.4 percent; P=1.0); at 180 days, the rates were 31.9 percent (95 percent confidence interval, 23.2 to 42.0 percent) and 31.5 percent (95 percent confidence interval, 22.8 to 41.7 percent; P=1.0), respectively. Methylprednisolone was associated with significantly increased 60- and 180-day mortality rates among patients enrolled at least 14 days after the onset of ARDS. Methylprednisolone increased the number of ventilator-free and shock-free days during the first 28 days in association with an improvement in oxygenation, respiratory-system compliance, and blood pressure with fewer days of vasopressor therapy. As compared with placebo, methylprednisolone did not increase the rate of infectious complications but was associated with a higher rate of neuromuscular weakness. These results do not support the routine use of methylprednisolone for persistent ARDS despite the improvement in cardiopulmonary physiology. In addition, starting methylprednisolone therapy more than two weeks after the onset of ARDS may increase the risk of death. (ClinicalTrials.gov number, NCT00295269.).
    New England Journal of Medicine 05/2006; 354(16):1671-84. DOI:10.1056/NEJMoa051693 · 54.42 Impact Factor

Publication Stats

12k Citations
1,334.42 Total Impact Points

Institutions

  • 2009
    • University of Toronto
      • Department of Medicine
      Toronto, Ontario, Canada
  • 1982–2009
    • University of Washington Seattle
      • • Division of Pulmonary and Critical Care Medicine
      • • Department of Medicine
      Seattle, Washington, United States
  • 1988–2005
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
  • 2004
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2001
    • University of Texas Health Science Center at Tyler
      Tyler, Texas, United States
  • 1999
    • University of Texas at Tyler
      • Department of Chemistry and Biochemistry
      Tyler, Texas, United States
  • 1996
    • Washington DC VA Medical Center
      Washington, Washington, D.C., United States
  • 1995
    • Fred Hutchinson Cancer Research Center
      Seattle, Washington, United States
  • 1994
    • Robert Wood Johnson Foundation
      Princeton, New Jersey, United States