Alice Gallo De Moraes

The Use of ECMO in HIV/AIDS with Pneumocystis jirovecii Pneumonia: A Case Report and Review of the Literature

There are few reports of extracorporeal membrane oxygenation (ECMO) therapy for respiratory failure because of Pneumocystis jirovecii pneumonia (PJP) in patients with acquired immunodeficiency syndrome (AIDS). None of the cases reported involvement of immune reconstitution inflammatory syndrome (IRIS), a paradoxical clinical worsening after the initiation of antiretroviral therapy (ART) in ART-naïve patients because of an exaggerated systemic inflammation with cell count recovery. We present a patient with newly diagnosed AIDS and PJP pneumonia that progressed to acute respiratory distress syndrome (ARDS) secondary to probable IRIS for which veno-venous ECMO was initiated. He transitioned to conventional ventilator after 57 days of ECMO therapy. However, he did not survive to hospital discharge. Combined with four previously reported cases of ARDS in human immunodeficiency virus patients secondary to PJP treated with ECMO, three of the five patients survived to ECMO decannulation. Extracorporeal membrane oxygenation is considered an accepted modality for adult patients with respiratory and/or cardiac failure refractory to maximal medical therapy. As ECMO becomes increasingly utilized in clinical practice, there is ongoing controversy regarding the appropriate selection of patients. In the past, contraindications to ECMO included immunocompromised states and conditions with known poor prognosis. The cases herein suggest the indications and contraindications warrant further discussion and research.

Ketamine and Propofol Combination (“Ketofol”) for Endotracheal Intubations in Critically Ill Patients: A Case Series

Case series Patient: Male, 77 • Male, 25 • Male, 63 • Male, 70 • Male, 70 • Female, 61 Final Diagnosis: — Symptoms: Hypotension • respiratory failure Medication: Ketamine • Propofol • Etomidate Clinical Procedure: Endotracheal intubation Specialty: Critical Care Medicine Objective: Educational Purpose (only if useful for a systematic review or synthesis) Background: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation. Case Series: We describe 6 cases in which the combination of ketamine and propofol (“ketofol”) was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations. Conclusions: This case series describes the use of the “ketofol” combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.

Effectiveness of hands-on tutoring and guided selfdirected learning versus self-directed learning alone to educate critical care fellows on mechanical ventilation - a pilot project

Background Physicians require extensive training to achieve proficiency in mechanical ventilator (MV) management of the critically ill patients. Guided self-directed learning (GSDL) is usually the method used to learn. However, it is unclear if this is the most proficient approach to teaching mechanical ventilation to critical care fellows. We, therefore, investigated whether critical care fellows achieve higher scores on standardized testing and report higher satisfaction after participating in a hands-on tutorial combined with GSDL compared to self-directed learning alone. Methods First-year Pulmonary and Critical Care Medicine (PCCM) fellows (n=6) and Critical Care Internal Medicine (CCIM) (n=8) fellows participated. Satisfaction was assessed using the Likert scale. MV knowledge assessment was performed by administering a standardized 25-question multiple choice pre- and posttest. For 2 weeks the CCIM fellows were exposed to GSDL, while the PCCM fellows received hands-on tutoring combined with GSDL. Results Ninety-three percentage (6 PCCM and 7 CCIM fellows, total of 13 fellows) completed all evaluations and were included in the final analysis. CCIM and PCCM fellows scored similarly in the pretest (64% vs. 52%, p=0.13). Following interventions, the posttest scores increased in both groups. However, no significant difference was observed based on the interventions (74% vs. 77%, p=0.39). The absolute improvement with the hands-on-tutoring and GSDL group was higher than GSDL alone (25% vs. 10%, p=0.07). Improved satisfaction scores were noted with hands-on tutoring. Conclusions Hands-on tutoring combined with GSDL and GSDL alone were both associated with an improvement in posttest scores. Absolute improvement in test and satisfaction scores both trended higher in the hands-on tutorial group combined with GSDL group.Background Physicians require extensive training to achieve proficiency in mechanical ventilator (MV) management of the critically ill patients. Guided self-directed learning (GSDL) is usually the method used to learn. However, it is unclear if this is the most proficient approach to teaching mechanical ventilation to critical care fellows. We, therefore, investigated whether critical care fellows achieve higher scores on standardized testing and report higher satisfaction after participating in a hands-on tutorial combined with GSDL compared to self-directed learning alone. Methods First-year Pulmonary and Critical Care Medicine (PCCM) fellows (n=6) and Critical Care Internal Medicine (CCIM) (n=8) fellows participated. Satisfaction was assessed using the Likert scale. MV knowledge assessment was performed by administering a standardized 25-question multiple choice pre- and posttest. For 2 weeks the CCIM fellows were exposed to GSDL, while the PCCM fellows received hands-on tutoring combined with GSDL. Results Ninety-three percentage (6 PCCM and 7 CCIM fellows, total of 13 fellows) completed all evaluations and were included in the final analysis. CCIM and PCCM fellows scored similarly in the pretest (64% vs. 52%, p=0.13). Following interventions, the posttest scores increased in both groups. However, no significant difference was observed based on the interventions (74% vs. 77%, p=0.39). The absolute improvement with the hands-on-tutoring and GSDL group was higher than GSDL alone (25% vs. 10%, p=0.07). Improved satisfaction scores were noted with hands-on tutoring. Conclusions Hands-on tutoring combined with GSDL and GSDL alone were both associated with an improvement in posttest scores. Absolute improvement in test and satisfaction scores both trended higher in the hands-on tutorial group combined with GSDL group.

Stress and burnout among critical care fellows: preliminary evaluation of an educational intervention

Background Despite a demanding work environment, information on stress and burnout of critical care fellows is limited. Objectives To assess 1) levels of burnout, perceived stress, and quality of life in critical care fellows, and 2) the impact of a brief stress management training on these outcomes. Methods In a tertiary care academic medical center, 58 critical care fellows of varying subspecialties and training levels were surveyed to assess baseline levels of stress and burnout. Twenty-one of the 58 critical care fellows who were in the first year of training at the time of this initial survey participated in a pre-test and 1-year post-test to determine the effects of a brief, 90-min stress management intervention. Results Based on responses (n=58) to the abbreviated Maslach Burnout Inventory, reported burnout was significantly lower in Asian fellows (p=0.04) and substantially higher among graduating fellows (versus new and transitioning fellows) (p=0.02). Among the intervention cohort, burnout did not significantly improve – though two-thirds of fellows reported using the interventional techniques to deal with stressful situations. Fellows who participated in the intervention rated the effectiveness of the course as 4 (IQR=3.75–5) using the 5-point Likert scale. Conclusions In comparison with the new and transitioning trainees, burnout was highest among graduating critical care fellows. Although no significant improvements were found in first-year fellows’ burnout scores following the single, 90-min training intervention, participants felt the training did provide them with tools to apply during stressful situations.

Patent foramen ovale in idiopathic pulmonary arterial hypertension: Long-term risk and morbidity.

INTRODUCTION Little is known about the presence of patent foramen ovale in idiopathic pulmonary arterial hypertension. While there is suspected worsening of hypoxemia confounding assessment and management of pulmonary hypertension, as well as possible increased morbidity from paradoxical emboli, there may be theoretical relief of worsening right-sided pressures by the same mechanism of right-to-left shunting. METHODS Retrospective review of consecutive patients diagnosed with idiopathic pulmonary arterial hypertension (WHO Group 1) via right heart catheterization, from 1998 to 2010. All patients also underwent a four chamber transthoracic echocardiogram with agitated saline contrast for the evaluation of patent foramen ovale. Primary clinical data was collected and compared between patients with and without patent foramen ovale along with univariable and multivariable predictors of long term survival. RESULTS One hundred and fifty five patients were included in the study, 42 with patent foramen ovale (27%). Patients with patent foramen ovale were younger at pulmonary arterial hypertension diagnosis and trended towards higher right ventricular systolic pressures on echocardiography and mean pulmonary arterial pressures by right heart catheterization. Predictors of mortality included age, diffusing capacity for carbon monoxide, and severe hypoxemia. Only diffusing capacity and age were predictive of mortality after adjustment for a priori covariables. CONCLUSION Patent foramen ovale is seen in a quarter of patients with idiopathic pulmonary arterial hypertension and associated with increased prevalence of severe hypoxemia but had no effect on long term survival.

Severe Acute Cardiopulmonary Failure Related to Gadobutrol Magnetic Resonance Imaging Contrast Reaction: Successful Resuscitation with Extracorporeal Membrane Oxygenation

Nonanaphylactic noncardiogenic pulmonary edema leading to cardiorespiratory arrest related to the magnetic resonance imaging contrast agent gadobutrol has rarely been reported in the literature. Rarer is the association of hypokalemia with acidosis. We report 2 patients who had severe pulmonary edema associated with the use of gadobutrol contrast in the absence of other inciting agents or events. These cases were unique not only for their rare and severe presentations but also because they exemplified the increasing role of extracorporeal membrane oxygenation in resuscitation. Emergency extracorporeal membrane oxygenation resuscitation can be rapidly initiated and successful in the setting of a well-organized workflow, and it is a viable alternative and helps improve patient outcome in cases refractory to conventional resuscitative measures.

In-Hospital Management and Follow-Up Treatment of Venous Thromboembolism: Focus on New and Emerging Treatments

Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep venous thrombosis (DVT), is a major cause of morbidity and mortality of particular relevance for intensivists and hospitalists. Acute VTE is usually managed with parenteral unfractionated heparin or low-molecular-weight heparin, followed by an oral vitamin K antagonist. Data are lacking for optimal treatment of less common occurrences, such as upper extremity DVT, and for approaches such as thrombolysis for PE associated with early signs of hemodynamic compromise or inferior vena cava filters when anticoagulation is contraindicated. Direct oral anticoagulants (DOACs) including apixaban, dabigatran, edoxaban, and rivaroxaban are now added to the armamentarium of agents available for acute management of VTE and/or reducing the risk of recurrence. This review outlines an algorithmic approach to acute VTE treatment: from aggressive therapies when anticoagulation may be inadequate, to alternative choices when anticoagulation is contraindicated, to anticoagulant options in the majority of patients in whom anticoagulation is appropriate. Evidence-based guidelines and the most recent DOAC clinical trial data are discussed in the context of the standard of care. Situations and treatment approaches for which data are unavailable or insufficient are identified. VTE therapy in care transitions is discussed, as are choices for secondary prevention.

Important clinician information needs about family members in the intensive care unit

PURPOSE Clinicians often lack key information regarding intensive care unit (ICU) families. Our objective was to identify (1) important information for clinicians to know about ICU families when making decisions and (2) important information for families to know about patients from clinicians. MATERIALS AND METHODS We identified important information items through a literature review and semistructured interviews. A separate cohort of family members, nurses, and physicians from 2 ICUs in a single institution were asked to prioritize the identified information as necessary for decision making. RESULTS We identified 21 items important for clinicians to know about families and 32 items important for families to know about patients from clinicians. Themes important for clinicians to know about family members included family background, questions, understanding, goals, concerns, well-being, and requests for additional help. Themes important for families to know about the patient included diagnosis, treatments, prognosis, clinical status, schedule, comfort, goals of care, medical team, and family participation. CONCLUSIONS Through qualitative and quantitative analysis, we identified important information for ICU clinicians to know about family members and for family members to know about patients. The identified information can be used to guide strategies and tools to improve assessment of and communication with families.

Epithelioid angiosarcoma: A rare cause of pericarditis and pleural effusion

Angiosarcomas are rare cancers accounting for less than 2% of all soft tissue sarcomas. We report the case of an unusual presentation of pleural epithelioid angiosarcoma in a patient with constrictive pericarditis and recurrent pleural effusion. A 62 year old smoker presented with acute chest pain. ECG showed diffuse elevation of ST segments in the precordial leads. After extensive evaluation, he was diagnosed with viral pericarditis and treated with colchicine. Two weeks later the patient presented to the emergency department with a large right pleural effusion. Evaluation of the pleural fluid obtained from a thoracentesis revealed an exudative effusion with negative microbial studies and no evidence of malignant cells. His pleural effusion re-accumulated rapidly, requiring repeated thoracenteses over several weeks. Medical thoracoscopy was performed and pleural biopsy revealed primary pleural epithelioid angiosarcoma. Staging PET scan revealed malignant enhancement of right pleura, pericardium, right iliac bone and right shoulder. He died suddenly within 6 weeks of diagnosis, prior to initiating palliative chemotherapy. Pleural angiosarcoma should be considered in the differential diagnosis of recurrent pleural effusions of unknown etiology. Negative cytology does not rule out the diagnosis; excisional biopsy is required. Reported risk factors include asbestos exposure, prior chest radiation, active smoking and history of complicated pleural tuberculosis. Pleural epithelioid angiosarcomas carry a very poor prognosis, with the majority of patients dying within months of diagnosis.

Characteristics of Mycobacterium avium complex (MAC) pulmonary disease in previously treated lung cancer patients

Introduction Mycobacterium avium complex (MAC) is responsible for a large portion of non-tuberculous mycobacterial (NTM) infections worldwide. Host factors such as active malignancy, immunosuppression, chronic obstructive pulmonary disease (COPD) and bronchiectasis increase the risk of MAC infection. However, the relationship between previously treated lung cancer with subsequent development of MAC pulmonary disease and treatment outcomes have not been previously studied. Methods We retrospectively identified all patients with lung cancer and MAC pulmonary disease documented in medical records at Mayo Clinic between January 2005 and October 2016. Patients who were diagnosed with MAC pulmonary disease before or at the time of lung cancer diagnosis were excluded. Patients meeting all inclusion criteria underwent chart review for prior oncologic treatments, clinical characteristics, and MAC treatment response. Results We identified 13 patients with MAC pulmonary disease and prior lung cancer, including 4 men and 9 women. Eight patients had structural lung disease that can predispose to MAC pulmonary disease, including bronchiectasis (23.0%) and COPD (46.2%). Four (30.8%) had no apparent immunosuppression or other risk factor(s) for MAC pulmonary disease. Primary pulmonary malignancies included pulmonary carcinoid, adenocarcinoma, and squamous cell carcinoma. Ten (76.9%) patients were started on antimicrobial treatment for MAC, and 8 (61.5%) patients completed MAC treatment with 6 (46.1%) patients achieving symptomatic improvement. Conclusion MAC pulmonary disease in previously treated lung cancer can occur without apparent risk factors for this NTM infection. Symptomatic improvement with MAC antimicrobial therapy appears to be lower than expected but comorbidities might influence outcomes in this patient population.