Alice Gray

One-Year Trajectories of Care and Resource Utilization for Recipients of Prolonged Mechanical Ventilation: A Cohort Study

BACKGROUND Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care facilities or about the associated resource utilization. OBJECTIVE To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation. DESIGN 1-year prospective cohort study. SETTING 5 intensive care units at Duke University Medical Center, Durham, North Carolina. PARTICIPANTS 126 patients receiving prolonged mechanical ventilation (defined as ventilation for >or=4 days with tracheostomy placement or ventilation for >or=21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year. MEASUREMENTS Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. Physicians were interviewed in the hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and interfacility transportation. Medicare claims data were used to assign costs for postacute care. RESULTS 103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions [interquartile range, 3 to 5 transitions]), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 year, 11 patients (9%) had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency [4 patients; 21%] or dead [56 patients; 44%]). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was

Expectations and Outcomes of Prolonged Mechanical Ventilation

306,135 (SD,

Acute Eosinophilic Pneumonia Secondary to Daptomycin: A Report of Three Cases

285,467), and total cohort cost was

Antibody Desensitization Therapy in Highly Sensitized Lung Transplant Candidates

38.1 million, for an estimated

Ambulatory ECMO as a Bridge to Lung Transplant in a Previously Well Pediatric Patient With ARDS

3.5 million per independently functioning survivor at 1 year. LIMITATION The results of this single-center study may not be applicable to other centers. CONCLUSION Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support. PRIMARY FUNDING SOURCE None.

Lung transplantation at Duke

Objective:To compare prolonged mechanical ventilation decision-makers’ expectations for long-term patient outcomes with prospectively observed outcomes and to characterize important elements of the surrogate-physician interaction surrounding prolonged mechanical ventilation provision. Prolonged mechanical ventilation provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the prolonged mechanical ventilation decision-making process could provide an explanation for this phenomenon. Design:Prospective observational cohort study. Setting:Academic medical center. Patients:A total of 126 patients receiving prolonged mechanical ventilation. Interventions:None. Measurements and Main Results:Participants were interviewed at the time of tracheostomy placement about their expectations for 1-yr patient survival, functional status, and quality of life. These expectations were then compared with observed 1-yr outcomes measured with validated questionnaires. The 1-yr follow-up was 100%, with the exception of patient death or cognitive inability to complete interviews. At 1 yr, only 11 patients (9%) were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for 1-yr patient survival (n = 117, 93%), functional status (n = 90, 71%), and quality of life (n = 105, 83%). In contrast, fewer physicians described high expectations for survival (n = 54, 43%), functional status (n = 7, 6%), and quality of life (n = 5, 4%). Surrogate-physician pair concordance in expectations was poor (all &kgr; = <0.08), as was their accuracy in outcome prediction (range = 23%–44%). Just 33 surrogates (26%) reported that physicians discussed what to expect for patients’ likely future survival, general health, and caregiving needs. Conclusions:One-year patient outcomes for prolonged mechanical ventilation patients were significantly worse than expected by patients’ surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates’ unreasonably optimistic expectations seem to be potentially modifiable deficiencies in surrogate-physician interactions.

Antibody depletion strategy for the treatment of suspected antibody-mediated rejection in lung transplant recipients: Does it work?

We describe 3 cases of daptomycin-induced pulmonary toxic effects that are consistent with drug-induced acute eosinophilic pneumonia. Patients presented similarly with dyspnea, cough, hypoxia, and diffuse ground-glass opacities at chest computed tomography. Clinical suspicion for this adverse drug event and cessation of daptomycin until definitive diagnosis can be made is crucial.

An interesting case of positional hypoxia: the effect of multiple synergistic pathological conditions.

As HLAs antibody detection technology has evolved, there is now detailed HLA antibody information available on prospective transplant recipients. Determining single antigen antibody specificity allows for a calculated panel reactive antibodies (cPRA) value, providing an estimate of the effective donor pool. For broadly sensitized lung transplant candidates (cPRA ≥ 80%), our center adopted a pretransplant multi‐modal desensitization protocol in an effort to decrease the cPRA and expand the donor pool. This desensitization protocol included plasmapheresis, solumedrol, bortezomib and rituximab given in combination over 19 days followed by intravenous immunoglobulin. Eight of 18 candidates completed therapy with the primary reasons for early discontinuation being transplant (by avoiding unacceptable antigens) or thrombocytopenia. In a mixed‐model analysis, there were no significant changes in PRA or cPRA changes over time with the protocol. A sub‐analysis of the median fluorescence intensity (MFI) change indicated a small decline that was significant in antibodies with MFI 5000–10 000. Nine of 18 candidates subsequently had a transplant. Posttransplant survival in these nine recipients was comparable to other pretransplant‐sensitized recipients who did not receive therapy. In summary, an aggressive multi‐modal desensitization protocol does not significantly reduce pretransplant HLA antibodies in a broadly sensitized lung transplant candidate cohort.

Correlation between sinus and lung cultures in lung transplant patients with cystic fibrosis: Sinus and Lung Cultures in CF Transplant

Extracorporeal membrane oxygenation (ECMO) is increasingly implemented in patients with end-stage pulmonary disease as a bridge to lung transplant. Several centers have instituted an approach that involves physical rehabilitation and ambulation for patients supported with ECMO. Recent reports describe the successful use of ambulatory ECMO in patients with chronic respiratory illnesses being bridged to lung transplant. We describe the first case of a previously healthy pediatric patient with acute respiratory failure successfully supported with ambulatory ECMO as a bridge to lung transplant after an unsuccessful bridge to recovery. Although there are challenges associated with awake and ambulatory ECMO in children, this strategy represents an exciting breakthrough and a potential paradigm shift in ECMO management for pediatric acute respiratory failure.

Management of Dofetilide Overdose in a Patient with Known Cocaine Abuse

Lung transplantation represents the gold-standard therapy for patients with end-stage lung disease. Utilization of this therapy continues to rise. The Lung Transplant Program at Duke University Medical Center was established in 1992, and since that time has grown to one of the highest volume centers in the world. The program to date has performed over 1,600 lung transplants. This report represents an up-to-date review of the practice and management strategies employed for safe and effective lung transplantation at our center. Specific attention is paid to the evaluation of candidacy for lung transplantation, donor selection, surgical approach, and postoperative management. These evidence-based strategies form the foundation of the clinical transplantation program at Duke.