Ariel Modrykamien

Impact of COPD on Postoperative Outcomes: Results From a National Database

BACKGROUND Although COPD affects large sections of the population, its effects on postoperative outcomes have not been rigorously studied. The objectives of this study were to describe the prevalence of COPD in patients undergoing surgery and to analyze the associations between COPD and postoperative morbidity, mortality, and hospital length of stay. METHODS Patients with COPD who underwent surgery were identified from the National Surgical Quality Improvement Program database (2007-2008). Univariate and multivariate analyses were performed on this multicenter, prospective data set (N = 468,795). RESULTS COPD was present in 22,576 patients (4.82%). These patients were more likely to be older, men, white, smokers, and taking corticosteroids and had a lower BMI (P < .0001 for each). Median length of stay was 4 days for patients with COPD vs 1 day in those without COPD (P < .0001). Thirty-day morbidity rates were 25.8% and 10.2% for patients with and without COPD, respectively (P < .0001). Thirty-day death rates were 6.7% and 1.4% for patients with and without COPD, respectively (P < .0001). After controlling for > 50 comorbidities through logistic regression modeling, COPD was independently associated with higher postoperative morbidity (OR, 1.35; 95% CI, 1.30-1.40; P < .0001) and mortality (OR, 1.29; 95% CI, 1.19-1.39; P < .0001). Multivariate analyses with each individual postoperative complication as the outcome of interest showed that COPD was associated with increased risk for postoperative pneumonia, respiratory failure, myocardial infarction, cardiac arrest, sepsis, return to the operating room, and renal insufficiency or failure (P < .05 for each). CONCLUSIONS COPD is common among patients undergoing surgery and is associated with increased morbidity, mortality, and length of stay.

Airway pressure release ventilation: an alternative mode of mechanical ventilation in acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) results in collapse of alveoli and therefore poor oxygenation. In this article, we review airway pressure release ventilation (APRV), a mode of mechanical ventilation that may be useful when, owing to ARDS, areas of the lungs are collapsed and need to be reinflated (“recruited”), avoiding cyclic alveolar collapse and reopening. This mode may be useful in situations in which the lungs need to be recruited (reinflated) and held open.

Original ResearchCOPDImpact of COPD on Postoperative Outcomes: Results From a National Database

BACKGROUND Although COPD affects large sections of the population, its effects on postoperative outcomes have not been rigorously studied. The objectives of this study were to describe the prevalence of COPD in patients undergoing surgery and to analyze the associations between COPD and postoperative morbidity, mortality, and hospital length of stay. METHODS Patients with COPD who underwent surgery were identified from the National Surgical Quality Improvement Program database (2007-2008). Univariate and multivariate analyses were performed on this multicenter, prospective data set (N = 468,795). RESULTS COPD was present in 22,576 patients (4.82%). These patients were more likely to be older, men, white, smokers, and taking corticosteroids and had a lower BMI (P < .0001 for each). Median length of stay was 4 days for patients with COPD vs 1 day in those without COPD (P < .0001). Thirty-day morbidity rates were 25.8% and 10.2% for patients with and without COPD, respectively (P < .0001). Thirty-day death rates were 6.7% and 1.4% for patients with and without COPD, respectively (P < .0001). After controlling for > 50 comorbidities through logistic regression modeling, COPD was independently associated with higher postoperative morbidity (OR, 1.35; 95% CI, 1.30-1.40; P < .0001) and mortality (OR, 1.29; 95% CI, 1.19-1.39; P < .0001). Multivariate analyses with each individual postoperative complication as the outcome of interest showed that COPD was associated with increased risk for postoperative pneumonia, respiratory failure, myocardial infarction, cardiac arrest, sepsis, return to the operating room, and renal insufficiency or failure (P < .05 for each). CONCLUSIONS COPD is common among patients undergoing surgery and is associated with increased morbidity, mortality, and length of stay.

The ICU Follow-Up Clinic: A New Paradigm for Intensivists

Over the last 15 years the management of patients admitted in the ICU has changed dramatically. A growing number of well designed randomized controlled studies have been published, resulting in improved medical care and reduction of short-term morbidity and mortality. Despite these important achievements, little attention has been placed on the long-term complications of subjects discharged from the ICU. This review will focus on the most common long-term outcomes post-ICU admission, and will emphasize the importance of developing ICU clinics to provide comprehensive care to ICU survivors. We also describe our experience regarding the organization, functioning, and limitations for the development of our post-ICU clinic.

The effect of a mechanical ventilation discontinuation protocol in patients with simple and difficult weaning: impact on clinical outcomes.

OBJECTIVE: We sought to determine whether the utilization of a respiratory therapist (RT) driven mechanical ventilation weaning protocol is associated with improvement in clinical outcomes in subjects with simple versus difficult weaning. METHODS: This was a retrospective analysis of prospectively collected data obtained during a quality improvement project. We collected data on 803 consecutive mechanically ventilated patients admitted to the ICU of an academic tertiary care hospital. We compared an RT-driven weaning protocol to a physician-driven weaning strategy. RESULTS: Of the 803 patients, 651 with simple weaning and 131 with difficult weaning were included in the analysis. In the subjects with simple weaning, 514 (79%) were weaned with the RT-driven protocol. Among the difficult weaning subjects, 101(77.1%) were liberated with the RT-driven protocol. A multivariate analysis, which included Acute Physiology and Chronic Health Evaluation II, body mass index, and type of primary ICU team under which the subjects were admitted, revealed a significant difference in ventilator-free days at 28-days, which supports the RT-driven protocol over the physician-driven strategy. Specifically, the RT-driven protocol increased ventilator-free days by 20.92% and 68.2% among subjects with simple and difficult weaning, respectively. A multivariate analysis of ICU mortality and extubation failure found no significant difference between the RT-driven protocol and the physician-driven strategy. CONCLUSIONS: The RT-driven weaning protocol increased ventilator-free days among subjects with simple and difficult weaning, with no significant differences in ICU mortality or extubation failure.

The acute respiratory distress syndrome.

The acute respiratory distress syndrome (ARDS) is a major cause of acute respiratory failure. Its development leads to high rates of mortality, as well as short- and long-term complications, such as physical and cognitive impairment. Therefore, early recognition of this syndrome and application of demonstrated therapeutic interventions are essential to change the natural course of this devastating entity. In this review article, we describe updated concepts in ARDS. Specifically, we discuss the new definition of ARDS, its risk factors and pathophysiology, and current evidence regarding ventilation management, adjunctive therapies, and intervention required in refractory hypoxemia.

Humidification during Mechanical Ventilation in the Adult Patient

Humidification of inhaled gases has been standard of care in mechanical ventilation for a long period of time. More than a century ago, a variety of reports described important airway damage by applying dry gases during artificial ventilation. Consequently, respiratory care providers have been utilizing external humidifiers to compensate for the lack of natural humidification mechanisms when the upper airway is bypassed. Particularly, active and passive humidification devices have rapidly evolved. Sophisticated systems composed of reservoirs, wires, heating devices, and other elements have become part of our usual armamentarium in the intensive care unit. Therefore, basic knowledge of the mechanisms of action of each of these devices, as well as their advantages and disadvantages, becomes a necessity for the respiratory care and intensive care practitioner. In this paper, we review current methods of airway humidification during invasive mechanical ventilation of adult patients. We describe a variety of devices and describe the eventual applications according to specific clinical conditions.

Extended Utilization of Noninvasive Ventilation for Acute Respiratory Failure and Its Clinical Outcomes

BACKGROUND: Noninvasive ventilation (NIV) has increasingly been used for the treatment of acute respiratory failure. Despite recommendations supporting its utilization in a limited group of patients, NIV is frequently relied on as a first line treatment. We conducted a retrospective study to assess whether the extended use of NIV is associated with worse clinical outcomes. METHODS: This was a retrospective review of a data set consisting of patients admitted with respiratory failure and treated with NIV. Based on guidelines, we grouped the patients on whether they had indications and/or contraindications for NIV: NIV indicated and not contraindicated; NIV indicated and contraindicated; NIV not indicated and not contraindicated; NIV not indicated and contraindicated. The need for endotracheal intubation, hospital mortality, and stay were compared between these 4 groups. RESULTS: Demographic data were not significantly different between the groups. Within the group of subjects with no contraindication for NIV, those with indication and with no indication intubation rates were 28% and 17%, respectively (P = .39). Among the group of subjects with indications for NIV, the rate of intubation was 28% for those with no contraindication and 56% in those with it (P = .13). In the group of subjects with no indication for NIV, the presence of contraindications was associated with higher rate of intubation, compared with those without contraindications (70% vs 17%, P = .002). CONCLUSIONS: This study supports the extended utilization of NIV for subjects without contraindications, and for subjects with indications despite the presence or absence of contraindications.

Cognitive impairment in ICU survivors: Assessment and therapy

Cognitive impairment occurs in up to one-third of intensive care patients and may affect one or more cognitive domains. Because data are scarce on therapies for this complication, prevention remains the prevailing strategy. In this review, we discuss the clinical approach to cognitive impairment after an intensive care unit (ICU) stay. Cognitive impairment occurs in up to one-third of patients after a stay in the intensive care unit. Prevention is the prevailing strategy, since data on treatment are scarce.

Serum hyperchloremia as a risk factor for acute kidney injury in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

A high serum chloride concentration has been associated with the development of acute kidney injury in critically ill patients. However, the association between hyperchloremia and acute kidney injury (AKI) in patients admitted with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) is unknown. A retrospective analysis of consecutive patients admitted with the diagnosis of STEMI and treated with PCI was performed. Subjects were classified as having hyper- or normochloremia based upon their admission serum chloride level. Multivariable logistic regression analyses were employed for the primary and secondary outcomes. The primary analysis evaluated whether high serum chloride on admission was associated with the development of AKI after adjusting for age, diabetes mellitus, admission systolic blood pressure, contrast volume used during angiography, Killip class, and need for vasopressor therapy or intraaortic balloon pump. The secondary analyses evaluated whether high serum chloride was associated with sustained ventricular tachycardia or fibrillation. Of 291 patients (26.1% female, mean age of 59.9 ± 12.6 years, and mean body mass index of 29.3 ± 6.1 kg/m2), 25 (8.6%) developed AKI. High serum chloride on admission did not contribute significantly to the development of AKI (odds ratio, 95%; confidence interval, 0.90 to 1.24). In addition, serum chloride on admission was not significantly associated with sustained ventricular tachycardia or fibrillation after adjusting for demographic and clinical covariates. In conclusion, our study demonstrated no association between baseline serum hyperchloremia and an increased risk of AKI in patients admitted with STEMI treated with PCI.