Rebecca Sell

University of California, San Diego, San Diego, California, United States

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Publications (17)89.43 Total impact


  • No preview · Article · Nov 2015 · Critical care medicine
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    ABSTRACT: Background: In cases of in-hospital-witnessed ventricular fibrillation/ventricular tachycardia (VF/VT) arrest, it is unclear whether cardiopulmonary resuscitation prior to defibrillation attempt or expedited stacked defibrillation attempt is superior. Methods: Retrospective, observational study of all admitted patients with continuous cardiac monitoring who suffered VF/VT arrest between July 2005 and June 2013. In the stacked shock period (2005-2008), institutional protocols advocated early defibrillation with administration of 3 stacked shocks with brief pauses between each single defibrillation attempt to confirm sustained VF/VT. During the initial chest compression period (2008-2011), the protocol was modified to perform a 2-minute period of chest compressions prior to each defibrillation, including the initial. In the modified stack shock period (2011-2013), for a monitored arrest, defibrillation attempts were expedited with up to 3 successive shocks administered for persistent VF/VT. In unmonitored arrest, chest compressions and ventilations were initiated prior to defibrillation. The primary outcome measure was survival to hospital discharge. Results: Six hundred sixty-one cardiopulmonary arrests were recorded during the study period, with 106 patients (16%) representing primary VF/VT. The incidence of VF/VT arrest did not vary significantly between the study periods (P= 0.16) Survival to hospital discharge for all primary VF/VT arrest victims decreased, then increased significantly from the stacked shock period to initial chest compression period to modified stacked shock period (58%, 18%, 71%, respectively, P < 0.01). Specific group differences were significant between the initial chest compression versus the stacked and modified stacked shock groups (all P < 0.01). Conclusion: Data suggest that monitored VF/VT should undergo expeditious defibrillation with use of stacked shocks. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine.
    No preview · Article · Oct 2015 · Journal of Hospital Medicine
  • Roxana Ghashghaei · Irene Thung · Grace Y. Lin · Rebecca E. Sell
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    ABSTRACT: Blood culture-negative endocarditis presents a clinical and diagnostic challenge. Here, we describe a patient with a delayed diagnosis of Bartonella henselae endocarditis.
    No preview · Article · Sep 2015 · Journal of Cardiology Cases
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    ABSTRACT: Investigate the relationship of initial PetCO2 values of patients during inpatient pulseless electrical activity (PEA) cardiopulmonary arrest with return of spontaneous circulation (ROSC) and survival to discharge. This study was performed in two urban, academic inpatient hospitals. Patients were enrolled from July 2009-July 2013. A comprehensive database of all inpatient resuscitative events is maintained at these institutions, including demographic, clinical, and outcomes data. Arrests are stratified by primary etiology of arrest using a priori criteria. Inpatients with PEA arrest for whom recorded PetCO2 was available were included in the analysis. Capnography data obtained after ROSC and/or more than 10minutes after initiation of CPR were excluded. Multivariable logistic regression was used to explore the association between initial PetCO2 >20mmHg and both ROSC and survival-to-discharge. A total of 50 patients with PEA arrest and pre-ROSC capnography were analyzed. CPR continued an average of 11.8minutes after initial PetCO2 was recorded confirming absence of ROSC at time of measurement. Initial PetCO2 was higher in patients with versus without eventual ROSC (25.3 ±14.4mmHg versus 13.4 ±6.9mmHg, p=0.003). After adjusting for age, gender, and arrest location (ICU versus non-ICU), initial PetCO2 >20mmHg was associated with increased likelihood of ROSC (adjusted OR 4.8, 95% CI 1.2-19.2, p=0.028). Initial PetCO2 was not significantly associated with survival-to-discharge (p=0.251). Initial PetCO2 >20mmHg during CPR was associated with ROSC but not survival-to-discharge among inpatient PEA arrest victims. This analysis is limited by relatively small sample size. Copyright © 2015. Published by Elsevier Ireland Ltd.
    No preview · Article · May 2015 · Resuscitation
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    ABSTRACT: Traditional resuscitation training models are inadequate to achieving and maintaining resuscitation competency. This analysis evaluates the effectiveness of a novel, performance improvement-based inpatient resuscitation programme. This was a prospective, before-and-after study conducted in an urban, university-affiliated hospital system. All inpatient adult cardiac arrest victims without an active Do Not Attempt Resuscitation order from July 2005 to June 2012 were included. The Advanced Resuscitation Training (ART) programme was implemented in Spring 2007 and included a unique treatment algorithm constructed around the capabilities of our providers and resuscitation equipment, a training programme with flexible format and content including early recognition concepts, and a comprehensive approach to performance improvement feeding directly back into training. Our inpatient resuscitation registry and electronic patient care record were used to quantify arrest rates and survival-to-hospital discharge before and after ART programme implementation. Multiple logistic regression analysis was used to adjust for age, gender, location of arrest, initial rhythm, and time of day. A total of 556 cardiac arrest victims were included (182 pre- and 374 post-ART). Arrest incidence decreased from 2.7 to 1.2 per 1,000 patient discharges in non-ICU inpatient units, with no change in ICU arrest rate. An increase in survival-to-hospital discharge from 21 to 45 percent (p<0.01) was observed following ART programme implementation. Adjusted odds ratios for survival-to-discharge (OR 2.2, 95% CI 1.4-3.4) and good neurological outcomes (OR 3.0, 95% CI 1.7-5.3) reflected similar improvements. Arrest-related deaths decreased from 2.1 to 0.5 deaths per 1,000 patient discharges in non-ICU areas and from 1.5 to 1.3 deaths per 1,000 patient discharges in ICU areas, and overall hospital mortality decreased from 2.2% to 1.8%. Implementation of a novel, performance improvement-based inpatient resuscitation programme was associated with a decrease in the incidence of cardiac arrest and improved clinical outcomes. Copyright © 2015. Published by Elsevier Ireland Ltd.
    No preview · Article · Apr 2015 · Resuscitation
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    ABSTRACT: In-hospital cardiopulmonary arrest (CPA) accounts for substantial morbidity and mortality. Rapid response teams (RRTs) are designed to prevent non-intensive care unit (ICU) CPA through early detection and intervention. However, existing evidence has not consistently demonstrated a clear benefit. To explore the effectiveness of a novel RRT program design to decrease non-ICU CPA and overall hospital mortality. This study was conducted from the start of fiscal year 2005 to 2011. In November 2007, our hospitals implemented RRTs as part of a novel resuscitation program. Charge nurses from each inpatient unit underwent training as unit-specific RRT members. Additionally, all inpatient staff received annual training in RRT concepts including surveillance and recognition of deterioration. We compared the incidence of ICU and non-ICU CPA from first complete preimplementation year 2006 to postimplementation years 2007 to 2011. Overall hospital mortality was also reported. The incidence of non-ICU CPA decreased, whereas the incidence of ICU CPA remained unchanged. Overall hospital mortality also decreased (2.12% to 1.74%, P < 0.001). The year-over-year change in RRT activations was inversely related to the change in Code Blue activations for each inpatient unit (r = -0.68, P < 0.001). Our novel RRT program was associated with a decreased incidence of non-ICU CPA and improved hospital mortality. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine. © 2015 Society of Hospital Medicine.
    No preview · Article · Mar 2015 · Journal of Hospital Medicine
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    ABSTRACT: Background: Inadvertent hyperventilation is associated with poor outcomes from traumatic brain injury (TBI). Hypocapnic cerebral vasoconstriction is well described and causes an immediate and profound decrease in cerebral perfusion. The hemodynamic effects of positive-pressure ventilation (PPV) remain incompletely understood but may be equally important, particularly in the hypovolemic patient with TBI. Objective: Preliminary report on the application of a previously described mathematical model of perfusion and ventilation to prehospital data to predict intrathoracic pressure. Methods: Ventilation data from 108 TBI patients (76 ground transported, 32 helicopter transported) were used for this analysis. Ventilation rate (VR) and end-tidal carbon dioxide (PetCO2) values were used to estimate tidal volume (VT). The values for VR and estimated VT were then applied to a previously described mathematical model of perfusion and ventilation. This model allows input of various lung parameters to define a pressure–volume relationship, then derives mean intrathoracic pressure (MITP) for various VT and VR values. For this analysis, normal lung parameters were utilized. Separate analyses were performed assuming either fixed or variable PaCO2–PetCO2 differences. Ground and air medical patients were compared with regard to VR, PetCO2, estimated VT, and predicted MITP. Results: A total of 10,647 measurements were included from the 108 TBI patients, representing about 13 minutes of ventilation per patient. Mean VR values were higher for ground patients versus air patients (21.6 vs. 19.7 breaths/min; p < 0.01). Estimated VT values were similar for ground and air patients (399 mL vs. 392 mL; p = NS) in the fixed model but not the variable (636 vs. 688 mL, respectively; p < 0.01). Mean PetCO2 values were lower for ground versus air patients (30.6 vs. 33.8 mmHg; p < 0.01). Predicted MITP values were higher for ground versus air patients, assuming either fixed (9.0 vs. 8.1 mmHg; p < 0.01) or variable (10.9 vs. 9.7 mmHg; p < 0.01) PaCO2–PetCO2 differences. Conclusions: Predicted MITP values increased with ventilation rates. Future studies to externally validate this model are warranted.
    Full-text · Article · Oct 2014 · Prehospital Emergency Care
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    ABSTRACT: Introduction: Inpatient cardiac arrest (CA) can be classified by primary etiology (respiratory, dysrhythmic, septic, etc.). The relationship between arrest etiology and hospital day of the event has not previously been described Methods: We performed a retrospective review of all adults with inpatient cardiac arrest at our tertiary academic hospital between July 2005 and June 2013. Arrests were stratified by primary etiology of arrest (e.g. ventilation issues due to hypoxia, dysrhythmia from ventricular fibrillation, etc.) using a priori criteria. Patients were stratified into three groups based on hospital day (HD) of arrest (HD1, HD2-7, HD>7). Patients were compared based on the incidence of arrest as well as clinical outcome [return of spontaneous circulation (ROSC), survival to-discharge, and good neurological outcome (CPC 1 or 2)] using multivariable logistic regression. Results: A total of 627 arrest victims were identified during the study period. These included 193 (30.8%) in group HD1, 206 (32.9%) in HD2-7, and 228 (36.4%) in HD>7. Distribution of patients into the three groups was associated with arrest etiology (p<0.001). Respiratory arrests occurred later (p<0.001) while dysrhythmic arrests occurred earlier in the admission (p=0.014). Septic etiology was not associated with hospital day of arrest. Later arrests were associated with lower survival-to-discharge (p=0.038) and neurological outcomes (p=0.002). No difference was observed for rate of ROSC (p=0.183). Conclusions: Hospital day of arrest is associated with arrest etiology. In addition, patients suffering CA earlier in admission have higher rates of survival-to-discharge and good neurological outcome.
    No preview · Conference Paper · Dec 2013
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    ABSTRACT: Introduction: Several studies have documented an early morning peak in the incidence of out-of-hospital cardiac arrest, particularly due to ventricular fibrillation (VF). Whether temporal variability exists for various etiologies of in-hospital cardiopulmonary arrest is unknown. Methods: We conducted a retrospective review of all adult patients admitted to a tertiary academic hospital who suffered cardiopulmonary arrest between July 2005 and June 2013. Patients were stratified based on arrest etiology (e.g. respiratory failure due to hypoxia, dysrhythmia from ventricular fibrillation, etc.) using a priori criteria. In addition, patients were stratified based on time of arrest using 6-hour intervals [interval 1 = 0800-1359, interval 2 = 1400-1959, interval 3 = 2000-0159, interval 4 = 0200-0759]. Multivariate logistical regression was used to explore the association between arrest etiology and time of arrest against clinical outcome [return of spontaneous circulation (ROSC), survival-to-discharge, good neurological outcomes (CPC 1 or 2)]. Results: A total of 627 eligible patients were identified during the study period. The highest frequency of arrest occurred in interval 1 (p=0.009). Septic arrests occurred most frequently during interval 4 (p=0.004), while vagal arrests occurred most frequently during intervals 1 and 2 (p=0.040). Tachyarrhythmic arrests did not display a temporal pattern (p=0.144). No association between time of arrest and outcome was observed for all patients (p=0.059). However, survival-to-discharge was higher among septic arrests occurring during interval 1 versus interval 4 (adjusted odds ratio 11.6, 95% CI 1.1-125.0, p=0.039]. Conclusions: In-hospital cardiac arrests display temporal variability based on arrest etiology. Septic arrests peak in the early morning hours while vagal arrests occur during working hours. This may reflect physiologic conditions, such as cortisol release, or to process of care.
    No preview · Conference Paper · Dec 2013

  • No preview · Conference Paper · Nov 2013

  • No preview · Conference Paper · Nov 2013
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    ABSTRACT: Previous research has demonstrated significant relationships between peri-shock pause and survival to discharge from out-of hospital shockable cardiac arrest (OHCA). To determine the impact of peri-shock pause on survival from OHCA during the ROC PRIMED randomized controlled trial. We included patients in the ROC PRIMED trial who suffered OHCA between June 2007and November 2009, presented with a shockable rhythm and had CPR process data for at least one shock. We used multivariable logistic regression to determine the association between peri-shock pause duration and survival to hospital discharge. Among 2006 patients studied, the median (IQR) shock pause duration was: pre-shock pause 15seconds (8, 22); post-shock pause 6seconds (4, 9); and peri-shock pause 22.0seconds (14, 31). After adjusting for Utstein predictors of survival as well as CPR quality measures, the odds of survival to hospital discharge were significantly higher for patients with pre-shock pause <10seconds (OR: 1.52, 95% CI: 1.09, 2.11) and peri-shock pause<20seconds (OR: 1.82, 95% CI: 1.17, 2.85) when compared to patients with pre-shock pause ≥20seconds and peri-shock pause ≥40seconds. Post-shock pause was not significantly associated with survival to hospital discharge. Results for neurologically intact survival (Modified Rankin Score ≤3) were similar to our primary outcome. In patients with cardiac arrest presenting in a shockable rhythm during the ROC PRIMED trial, shorter pre- and peri-shock pauses were significantly associated with higher odds of survival. Future cardiopulmonary education and technology should focus on minimizing all peri-shock pauses.
    No preview · Article · Oct 2013 · Resuscitation
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    ABSTRACT: Background: Compression pauses may be particularly harmful following the electrical recovery but prior to the mechanical recovery from cardiopulmonary arrest. Methods and results: A convenience sample of patients with out-of-hospital cardiac arrest (OOHCA) were identified. Data were exported from defibrillators to define compression pauses, electrocardiogram rhythm, PetCO2, and the presence of palpable pulses. Pulse-check episodes were randomly assigned to a derivation set (one-third) and a validation set (two-thirds). Both an unweighted and a weighted receiver-operator curve (ROC) analysis were performed on the derivation set to identify optimal thresholds to predict ROSC using heart rate and PetCO2. A sequential decision guideline was generated to predict the presence of ROSC during compressions and confirm perfusion once compressions were stopped. The ability of this decision guideline to correctly identify pauses in which pulses were and were not palpated was then evaluated. A total of 145 patients with 349 compression pauses were included. The ROC analyses on the derivation set identified an optimal pre-pause heart rate threshold of >40 beats min(-1) and an optimal PetCO2 threshold of >20 mmHg to predict ROSC. A sequential decision guideline was developed using pre-pause heart rate and PetCO2 as well as the PetCO2 pattern during compression pauses to predict and rapidly confirm ROSC. This decision guideline demonstrated excellent predictive ability to identifying compression pauses with and without palpable pulses (positive predictive value 95%, negative predictive value 99%). The mean latency period between recovery of electrical and mechanical cardiac function was 78 s (95% CI 36-120 s). Conclusions: Heart rate and PetCO2 can predict ROSC without stopping compressions, and the PetCO2 pattern during compression pauses can rapidly confirm ROSC. Use of a sequential decision guideline using heart rate and PetCO2 may reduce unnecessary compression pauses during critical moments during recovery from cardiopulmonary arrest.
    No preview · Article · Sep 2012 · Resuscitation
  • David Riker · Rebecca Sell
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    ABSTRACT: Malignant pleural effusion is a common cause of morbidity and mortality in patients suffering from end-stage metastatic cancer. Malignant pleural effusion is associated with a shortened survival of 3 to 12 months after diagnosis, with 1- and 6-month mortality rates of 54% and 85%, respectively. Nearly all medical management in these patients is directed toward palliation of symptoms caused by pleural fluid accumulation. Options for treatment are repeated thoracentesis, use of chronic indwelling catheters, pleurodesis, and pleuroperitoneal shunts. Associated procedure risks include infection, bleeding, pneumothorax, and respiratory failure. Transthoracic ultrasound use is advocated to minimize procedural risks for thoracentesis and indwelling pleural catheter (IPC) placement. Most patients with advanced metastatic cancer and pleural effusion are not suitable candidates for pleuroscopy-delivered pleurodesis. Therefore, IPC is more commonly chosen to palliate respiratory symptoms related to pleural fluid accumulation from pleural tumor burden. Although pleural catheter complications are low, malignant seeding of the pleural tract can occur. Transthoracic ultrasound use to determine the presence of pleural tract seeding in conjunction with guided percutaneous biopsy has not been described. We report the use of ultrasound-guided percutaneous biopsy to diagnose metastatic seeding of an IPC.
    No preview · Article · Apr 2012 · Journal of Bronchology and Interventional Pulmonology
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    ABSTRACT: Perishock pauses are pauses in chest compressions before and after defibrillatory shock. We examined the relationship between perishock pauses and survival to hospital discharge. We included out-of-hospital cardiac arrest patients in the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest who suffered arrest between December 2005 and June 2007, presented with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia), and had cardiopulmonary resuscitation process data for at least 1 shock (n=815). We used multivariable logistic regression to determine the association between survival and perishock pauses. In an analysis adjusted for Utstein predictors of survival, the odds of survival were significantly lower for patients with preshock pause ≥20 seconds (odds ratio, 0.47; 95% confidence interval, 0.27 to 0.82) and perishock pause ≥40 seconds (odds ratio, 0.54; 95% confidence interval, 0.31 to 0.97) compared with patients with preshock pause <10 seconds and perishock pause <20 seconds. Postshock pause was not independently associated with a significant change in the odds of survival. Log-linear modeling depicted a decrease in survival to hospital discharge of 18% and 14% for every 5-second increase in both preshock and perishock pause interval (up to 40 and 50 seconds, respectively), with no significant association noted with changes in the postshock pause interval. In patients with cardiac arrest presenting in a shockable rhythm, longer perishock and preshock pauses were independently associated with a decrease in survival to hospital discharge. The impact of preshock pause on survival suggests that refinement of automatic defibrillator software and paramedic education to minimize preshock pause delays may have a significant impact on survival.
    Full-text · Article · Jun 2011 · Circulation
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    ABSTRACT: The three-phase model of ventricular fibrillation (VF) arrest suggests a period of compressions to "prime" the heart prior to defibrillation attempts. In addition, post-shock compressions may increase the likelihood of return of spontaneous circulation (ROSC). The optimal intervals for shock delivery following cessation of compressions (pre-shock interval) and resumption of compressions following a shock (post-shock interval) remain unclear. To define optimal pre- and post-defibrillation compression pauses for out-of-hospital cardiac arrest (OOHCA). All patients suffering OOHCA from VF were identified over a 1-month period. Defibrillator data were abstracted and analyzed using the combination of ECG, impedance, and audio recording. Receiver-operator curve (ROC) analysis was used to define the optimal pre- and post-shock compression intervals. Multiple logistic regression analysis was used to quantify the relationship between these intervals and ROSC. Covariates included cumulative number of defibrillation attempts, intubation status, and administration of epinephrine in the immediate pre-shock compression cycle. Cluster adjustment was performed due to the possibility of multiple defibrillation attempts for each patient. A total of 36 patients with 96 defibrillation attempts were included. The ROC analysis identified an optimal pre-shock interval of <3s and an optimal post-shock interval of <6s. Increased likelihood of ROSC was observed with a pre-shock interval <3s (adjusted OR 6.7, 95% CI 2.0-22.3, p=0.002) and a post-shock interval of <6s (adjusted OR 10.7, 95% CI 2.8-41.4, p=0.001). Likelihood of ROSC was substantially increased with the optimization of both pre- and post-shock intervals (adjusted OR 13.1, 95% CI 3.4-49.9, p<0.001). Decreasing pre- and post-shock compression intervals increases the likelihood of ROSC in OOHCA from VF.
    No preview · Article · Jul 2010 · Resuscitation
  • Rebecca Sell · Daniel P. Davis

    No preview · Conference Paper · May 2010