[Show abstract][Hide abstract] ABSTRACT: Vascular rings are congenital malformations of the aortic arch. A double aortic arch (DAA), the most common type of vascular ring, results from the failure of the fourth embryonic branchial arch to regress, leading to an ascending aorta that divides into a left and right arch that fuse together to completely encircle the trachea and esophagus. The subsequent DAA causes compressive effects on the trachea and esophagus that typically manifests in infancy or early childhood. Adult presentations, particularly in the elderly, are exceedingly rare. Historically such patients have a long-standing history of dyspnea on exertion and dysphagia, with many assumed to have obstructive lung or intrinsic cardiac disease. We describe a case of an elderly woman who presented with respiratory failure due to DAA. In her case, surgery was not feasible and we describe our experience with airway stenting.
Preview · Article · Dec 2016 · Respiratory Medicine Case Reports
[Show abstract][Hide abstract] ABSTRACT: Hyperglycemia is a commonly encountered metabolic derangement in the ICU. Important cellular pathways, such as those related to oxidant stress, immunity, and cellular homeostasis, can become deranged with prolonged and uncontrolled hyperglycemia. There is additionally a complex interplay between nutritional status, ambient glucose concentrations, and protein catabolism. While the nuances of glucose management in the ICU have been debated, results from landmark studies support the notion that for most critically ill patients moderate glycemic control is appropriate, as reflected by recent guidelines. Beyond the target population and optimal glucose range, additional factors such as hypoglycemia and glucose variability are important metrics to follow. In this regard, new technologies such as continuous glucose sensors may help alleviate the risks associated with such glucose fluctuations in the ICU. In this review, we will explore the impact of hyperglycemia upon critical cellular pathways and how nutrition provided in the ICU affects blood glucose. Additionally, important clinical trials to date will be summarized. A practical and comprehensive approach to glucose management in the ICU will be outlined, touching upon important issues such as glucose variability, target population, and hypoglycemia.
No preview · Article · Nov 2015 · Seminars in Respiratory and Critical Care Medicine
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Hyperglycemia is common during critical illness and can adversely affect clinical outcomes. We sought to determine the prevalence of undiagnosed diabetes among medical intensive care unit (MICU) patients with stress hyperglycemia and the association between baseline glycemic control and mortality.
Materials and methods:
A prospective, observational cohort study was performed at a tertiary care MICU. Hemoglobin A1c (HbA1c) levels were obtained from any patient who developed hyperglycemia and all known diabetic patients. We assessed the prevalence of undiagnosed diabetes (defined by HbA1c) among patients with stress hyperglycemia, and the association between baseline glycemic control and mortality.
We enrolled 299 patients. One hundred two (34.1%) had no history and 197 (65.9%) had a history of diabetes. Of the nondiabetic patients, 14 (13.7%) had an HbA1c of at least 6.5%. There was a significant difference in mortality between patients with HbA1c less than 6.5% and those with HbA1c of at least 6.5% (19.3% vs 11.7%, P=.038), despite similar Acute Physiology and Chronic Health Evaluation II scores. There was no significant difference in demographic characteristics between these groups. Multivariable logistic regression revealed lower HbA1c levels to be significantly associated with increased hospital mortality (odds ratio, 1.92; 95% confidence interval, 1.30-2.85; P=.001).
A significant number of MICU patients with stress hyperglycemia have undiagnosed diabetes. Hyperglycemia with lower baseline HbA1c was associated with increased mortality.
No preview · Article · Jun 2014 · Journal of Critical Care
[Show abstract][Hide abstract] ABSTRACT: Introduction: ALF is defined by acute derangements in hepatic synthetic function accompanied by coagulopathy and encephalopathy. All cause mortality is cited to be 33%; patients with uncontrolled intracranial pressure (ICP) have rates >90%. However, liver transplantation confers an 80% survival. Prior case series support moderate TH as an effective bridge to transplantation and as a treatment modality for cerebral edema. We studied the feasibility of using TH outside of the research setting (notably, without the routine use of an invasive ICP monitor) and assessed the safety of moderate TH in a retrospective, matched cohort study conducted at Yale New Haven Hospital. Methods: We extracted data for consecutive patients (n=10) who received TH for ALF between January 2008 and January 2012. Decisions for TH initiation were made at the discretion of treating providers - however, a multidisciplinary guideline for advanced coma management was available. This suggested the use of TH (as one component of cerebral edema treatment) for those with ammonia > 70 mcg/dL, neuroimaging compatible with edema, and/or those with hyperreflexia or posturing. Surface cooling was achieved via the Arctic Sun device (Medivance) while utilizing a detailed protocol to guide hypothermia management. Included were: adults >18 years old without chronic liver disease and disease onset <3 months, coagulopathy with INR >1.5, and hepatic encephalopathy. We analyzed 8 ALF patients similarly with advanced hepatic encephalopathy (West Haven Grade III-IV) within the same time period, but who were not treated with TH (non-TH cohort). We applied the two-tailed Student's t-test and the two-tailed Fisher's exact test, as appropriate. Results: The TH and non-TH patients had similar demographic data, mean APACHE III (37.2 +/- 14.6 vs. 34.8 +/- 4.3, p=0.90) and MELD scores (37.2 +/- 14.6 vs. 34.8 +/- 4.3, p=0.65), encephalopathy grade (3.6 +/- 0.5 vs. 3.4 +/- 0.5, p=0.37), and ammonia levels (211.7 +/- 80.5 vs. 178 +/- 79.2 mcg/dL, p=0.39). Median time to initiate cooling in the TH group was 24.5 hrs (IQR:11.5-43 hours); median cooling hours was 72.5 hrs (IQR:35-119.5 hours). More patients in the TH group received adjuvant therapy using molecular adsorbent recirculating system (MARS) dialysis (80% TH vs. 0% non-TH group, p=0.001). Only 1 of10 in the TH group received an ICP monitor, none of the non-TH patients did (p=1.00). Despite prolonged application of TH, there was no significant difference in complications. No differences in mean fresh frozen plasma and packed red blood cell transfusion requirements (17.5 +/- 16.4 vs. 17.3 +/- 12.6 units, p=0.97; 5.4 +/- 4.7 vs. 5.4 +/- 3.3 units, p=0.99), documented infections (60% vs. 62.5%, p=1.00), or rates of hemodynamic compromise (10% vs. 25%, p=0.56) were found between the groups. Of the TH cohort, 70% were listed for transplant, compared to 50% in the non-TH group (p=0.20). Of those listed, 57% received an organ in the TH group, compared to 75% (p=1.00). Survival to discharge was similar (50% vs. 37.5%, p=0.66). Conclusions: Moderate TH without invasive ICP monitors is a safe and feasible therapeutic modality that can be applied to a high risk ALF cohort. Although previously published studies almost always necessitated the use of invasive ICP monitors, our survival and complication rates were comparable without. Given the high mortality associated with cerebral edema, we feel that TH is likely under-utilized as a management tool in this population. This study was not adequately powered to determine if TH can improve outcomes and survival in ALF patients with cerebral edema. In addition, there was a high coincident use of MARS. Larger studies will be needed to delineate the relative efficacy and safety of each.
[Show abstract][Hide abstract] ABSTRACT: SESSION TYPE: Cancer Cases IIPRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PMINTRODUCTION: "Crazy paving" on computed tomography (CT) coupled with periodic acid Schiff (PAS) staining suggests a diagnosis of pulmonary alveolar proteinosis (PAP) in the appropriate clinical context. However, neither test is specific. Advances in serologic testing for PAP and genetic testing obtained by bronchoscopic samples for lung cancer have altered diagnostic algorithms for both diseases. We present a unique case of diffuse lung adenocarcinoma initially masquerading as PAP.CASE PRESENTATION: A 54 year-old former smoker presented with progressive dyspnea and bronchorrhea. Her medical history included venous thromboembolism and social history included welding industrial copper wires. Chest x-ray revealed bilateral pulmonary infiltrates, and hypoxemia progressed despite two courses of antibiotics. After requiring intubation, CT showed diffuse ground glass opacities with smooth inter-/intra-lobular septal thickening and multiple areas of consolidation (Fig. 1). Bronchoalveolar lavage fluid (BALF) revealed copious PAS-positive granular material. After transfer to our institution for progressive respiratory failure, urgent left-sided segmental whole lung lavage (WLL) was performed, and anti-GM-CSF antibody testing was requested. BALF had less sediment than expected for classic PAP. Repeat WLL was performed with unilateral lung ventilation followed by transbronchial biopsies (TBBx). Anti-GM-CSF antibody testing was negative, and TBBx revealed non-mucinous invasive adenocarcinoma with micropapillary and lepidic growth pattern (Fig. 2) with positive KRAS mutation. The patient was started on carboplatin and pemetrexed chemotherapy while on mechanical ventilation and was ultimately extubated, able to leave the hospital for ongoing care.DISCUSSION: "Crazy paving" is classically found in PAP. The differential also includes malignancy, Pneumocystis carinii pneumonia, sarcoidosis, adult respiratory distress syndrome, and others. Though positive PAS staining of BALF material suggests PAP, it too is non-specific. As it stains for glycoproteins, it can be positive in lung cancer, sarcoidosis, IPF, and others. Anti-GM-CSF antibody testing is sensitive and specific for PAP, whereas transbronchial biopsies may distinguish this from other conditions causing radiographic and cytologic similarities. Specifically, TBBx can be performed in critically ill, ventilator-dependent patients and obtain sufficient tissue to diagnose diffuse lung cancer, perform mutational analysis, and exclude other etiologies.CONCLUSIONS: Whereas "crazy paving" and PAS staining suggest PAP, other disorders may manifest with both. Anti-GM-CSF antibody titers coupled with small volume TBBx can refine diagnostic dilemmas such as this, while providing necessary tissue for guiding therapy.1) Rossi SE, et al. "Crazy-paving" pattern at thin-section CT of the lungs: Radiologic-pathologic overview. RadioGraphics 2003;23:1509-192) Trapnell BC, et al. Pulmonary alveolar proteinosis. NEJM 2003;349:2527-39DISCLOSURE: The following authors have nothing to disclose: Kusum Mathews, O'Neil Green, Aditi Mathur, Jonathan Puchalski, Shyoko HonidenNo Product/Research Disclosure InformationYale School of Medicine, New Haven, CT.
[Show abstract][Hide abstract] ABSTRACT: To report our preliminary experience with the revised, more conservative Yale insulin infusion protocol (IIP) that targets blood glucose concentrations of 120 to 160 mg/dL.
We prospectively tracked clinical responses to the new IIP in our medical intensive care unit (ICU) by recording data on the first 115 consecutive insulin infusions that were initiated. All blood glucose values; insulin doses; nutritional support including intravenous dextrose infusions; caloric values for enteral and parenteral nutrition; and use of vasopressors, corticosteroids, and hemodialysis or continuous venovenous hemodialysis were collected from the hospital record.
The IIP was used 115 times in 90 patients (mean age, 62 [±14 years]; 51% male; 35% ethnic minorities; 66.1% with history of diabetes). The mean admission Acute Physiology and Chronic Health Evaluation II score was 24.4 (±7.5). The median duration of insulin infusion was 59 hours. The mean baseline blood glucose concentration was 306.1 (±89.8) mg/dL, with the blood glucose target achieved after a median of 7 hours. Once the target was reached, the mean IIP blood glucose concentration was 155.9 (±22.9) mg/dL (median, 150 mg/dL). The median insulin infusion rate required to reach and maintain the target range was 3.5 units/h. Hypoglycemia was rare, with 0.3% of blood glucose values recorded being less than 70 mg/dL and only 0.02% being less than 40 mg/dL. In all cases, hypoglycemia was rapidly corrected using intravenous dextrose with no evident untoward outcomes.
The updated Yale IIP provides effective and safe targeted blood glucose control in critically ill patients, in compliance with recent national guidelines. It can be easily implemented by hospitals now using the original Yale IIP.
No preview · Article · Dec 2011 · Endocrine Practice
[Show abstract][Hide abstract] ABSTRACT: Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.
No preview · Article · Aug 2011 · Journal of Intensive Care Medicine
[Show abstract][Hide abstract] ABSTRACT: Hyperglycemia is common in critical illness and has been associated with increased morbidity and mortality. An era of tight glucose control began when intensive insulin therapy was shown to improve outcomes in a single-center randomized trial. More recently, with the publication of additional studies, questions have been raised regarding the efficacy and safety of intensive glycemic management. This article will review the biologic mechanisms that may help us understand why and how hyperglycemia and insulin are relevant in critical illness. We will then explore insights gleaned from available clinical trials. Finally, we will discuss specific areas of controversy that relate to the implementation of glycemic control in the intensive care unit, such as the ideal glucose target and the importance of hypoglycemia.
No preview · Article · Nov 2010 · Journal of Intensive Care Medicine
[Show abstract][Hide abstract] ABSTRACT: Physical and psychological distress is exceedingly common among critically ill patients and manifests generically as agitation. The dangers of over- and undertreatment of agitation have been well described, and the intensive care unit (ICU) physician must strike a balance in the fast-paced, dynamic ICU environment. Identification of common reversible etiologies for distress may obviate the need for pharmacologic therapy, but most patients receive some combination of sedative, analgesic, and neuroleptic medications during the course of their critical illness. As such, understanding key pharmacologic features of commonly used agents is critical. Structured protocols and objective assessment tools can optimize drug delivery and may ultimately improve patient outcomes by reducing ventilator days, ICU length of stay, and by reducing cognitive dysfunction.
No preview · Article · Jul 2010 · Journal of Intensive Care Medicine
[Show abstract][Hide abstract] ABSTRACT: The exact prevalence of obesity among critically ill patients is not known, but some evidence suggests that in the United States one in four patients in the intensive care unit is obese. The authors review the physiologic alterations in obesity that are relevant in critical illness and highlight some common diseases associated with obesity. Various practical challenges in the care of the critically ill obese patient, including drug dosing, are also reviewed.
No preview · Article · Oct 2009 · Clinics in chest medicine
[Show abstract][Hide abstract] ABSTRACT: Recently, many studies have investigated the immunomodulatory effects of insulin and glucose control in critical illness. This review examines evidence regarding the relationship between diabetes and the development of acute lung injury/acute respiratory distress syndrome (ALI/ARDS), reviews studies of lung injury related to glycemic and nonglycemic metabolic features of diabetes, and examines the effect of diabetic therapies.
A MEDLINE/PubMed search from inception to August 1, 2008, was conducted using the search terms acute lung injury, acute respiratory distress syndrome, hyperglycemia, diabetes mellitus, insulin, hydroxymethylglutaryl-CoA reductase inhibitors (statins), angiotensin-converting enzyme inhibitor, and peroxisome proliferator-activated receptors, including combinations of these terms. Bibliographies of retrieved articles were manually reviewed.
Available studies were critically reviewed, and data were extracted with special attention to the human and animal studies that explored a) diabetes and ALI; b) hyperglycemia and ALI; c) metabolic nonhyperglycemic features of diabetes and ALI; and d) diabetic therapies and ALI.
Clinical and experimental data indicate that diabetes is protective against the development of ALI/ARDS. The pathways involved are complex and likely include effects of hyperglycemia on the inflammatory response, metabolic abnormalities in diabetes, and the interactions of therapeutic agents given to diabetic patients. Multidisciplinary, multifaceted studies, involving both animal models and clinical and molecular epidemiology techniques, are essential.
Preview · Article · Jul 2009 · Critical care medicine
[Show abstract][Hide abstract] ABSTRACT: Survival of patients presenting with acute liver failure (ALF) has improved because of earlier disease recognition, better understanding of pathophysiology of various insults leading to ALF, and advances in supportive measures including a team approach, better ICU care, and liver transplantation. This article focuses on patient management and evaluation that takes place in the ICU for patients who have acute liver injury. An organized team approach to decision making about critical care delivered during this period of time is important for achieving a good patient outcome.
Full-text · Article · Apr 2009 · Clinics in chest medicine
[Show abstract][Hide abstract] ABSTRACT: To investigate whether timing of intensive insulin therapy (IIT) after intensive care unit (ICU) admission influences outcome.
Single-center prospective cohort study in the 14-bed medical ICU of a 1,171-bed tertiary teaching hospital.
The study included 127 patients started on ITT within 48 h of ICU admission (early group) and 51 started on ITT thereafter (late group); the groups did not differ in age, gender, race, BMI, APACHE III, ICU steroid use, admission diagnosis, or underlying comorbidities.
The early group had more ventilator-free days in the first 28 days after ICU admission (median 12 days, IQR 0-24, vs. 1 day, 0-11), shorter ICU stay (6 days, IQR 3-11, vs. 11 days, vs. 7-17), shorter hospital stay (15 days, IQR 9-30, vs. 25 days, 13-43), lower ICU mortality (OR 0.48), and lower hospital mortality (OR 0.27). On multivariate analysis, early therapy was still associated with decreased hospital mortality (ORadj 0.29). The strength and direction of association favoring early IIT was consistent after propensity score modeling regardless of method used for analysis.
Early IIT was associated with better outcomes. Our results raise questions about the assumption that delayed administration of IIT has the same benefit as early therapy. A randomized study is needed to determine the optimal timing of therapy.
Preview · Article · Jun 2008 · Intensive Care Medicine
[Show abstract][Hide abstract] ABSTRACT: To examine physician practice in, and the costs of, prescribing inhaled bronchodilators to mechanically ventilated patients who do not have obstructive lung disease.
This was a prospective cohort study at 2 medical intensive care units at 2 tertiary-care academic medical centers, over a 6-month period. Included were the patients who required > or = 24 hours of mechanical ventilation but did not have obstructive lung disease. Excluded were patients who had obstructive lung disease and/or who had undergone > 24 hours of mechanical ventilation outside the study intensive care units.
Of the 206 patients included, 74 (36%) were prescribed inhaled bronchodilators without clear indication. Sixty-five of those 74 patients received both albuterol and ipratropium bromide, usually within the first 3 days of intubation (58 patients). Patients prescribed bronchodilators were more hypoxemic; their mean P(aO(2))/F(IO(2)) ratio was lower (188 mm Hg versus 238 mm Hg, p = 0.004), and they were more likely to have pneumonia (53% vs 33%, p = 0.007). The mean extra cost for bronchodilators was 449.35 dollars per patient. Between the group that did receive bronchodilators and the group that did not, there was no significant difference in the incidence of ventilator-associated pneumonia, tracheostomy, or mortality. The incidence of tachyarrhythmias was similar (15% vs 22%, p = 0.25).
A substantial proportion of mechanically ventilated patients without obstructive lung disease received inhaled bronchodilators.